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Gynoplastic  Technology 


WITH    A    CHAPTER    ON 

'SACRAL    ANESTHESIA- 


ARNOLD  STURMDORF,  M.D. 

Clinical  Professor  of  Gynecology,  New  York  Polyclinic  Medical  School; 

Visiting  Gynecologist,  New  York  Polyclinic  Hospital;   Consulting 

Gynecologist  to  the  Manhattan  State   Hospital;    Fellow  of 

the  American  College  of  Surgeons;  Fellow  of  the 

New  York  Academy  of  Medicine;    Fellow  of 

the  American  Medical  Association, 

Etc.,  Etc. 


Illustrated  with  152  Half-tone  and  Photo-engravings  in  the 
Text,  some  in  Colors,  and  23  Full-page  Plates, 
with  35  Figures,  all  in  Colors 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,  Publishers 

English  Depot 

Stanley  Phillips,  London 

1920 


COPYRIGHT,   1919 

BY 

F.    A.    DAVIS    COMPANY 


Copyright,  Great  Britain.    All  rights  reserved 


PRESS   OF 

F.    A.     DAVIS    COMPANY 

PHILADELPHIA,   U.S.A. 


PREFACE. 

The  evolution  of  technological  progress,  and  the 
promulgation  of  its  advanced  basic  conceptions,  must 
of  necessity  contend  with  prevailing  principles  of 
practice,  some  of  which  are  founded  on  theories  of 
pathology  long  abandoned,  some  due  to  misdirected 
research  or  erroneous  clinical  deductions,  while  others 
present  the  mere  relics  of  an  obsolete  dogma,  upheld 
by  authoritative  sanction,  which  perpetuates  surgical 
measures  that  can  no  longer  be  defended  on  either 
theoretical  or  practical  grounds. 

Attempts  at  plastic  restoration  of  the  injured  birth 
canal  present  the  very  genesis  of  gynecological  sur- 
gery. As  an  art,  these  reconstructive  procedures  were 
developed  to  a  high  degree  of  perfection  by  the  in- 
genuity of  Sims,  Emmet,  Simon,  Hegar,  Schroeder 
and  others,  but  as  a  science  the  technological  prin- 
ciples standardized  by  these  master-minds  are  no 
longer  tenable. 

The  present  volume  embodies  an  elaborated  com- 
pilation of  the  author's  previous  publications  on  the 
various  phases  of  gynecoplastic  technology. 

Each  topic  is  presented  in  monographic  form,  as 
better  adapted  to  the  exposition  of  its  controversial 
aspects. 

(iii) 


iv  PREFACE. 

The  various  operative  procedures  are  detailed  and 
illustrated  to  illuminate  underlying  principles  of  prac- 
tice rather  than  to  standardize  any  individual  method 
as  one  of  universal  applicability,  while  the  historical 
data  are  given  only  where  they  reveal  the  progressive 
stages  in  the  evolution  of  advanced  gynecoplastic 
technology.  Finally,  as  no  modern  work  on  regional 
surgery  would  be  complete  without  a  consideration  of 
sacral  anesthesia,  a  chapter  on  "Sacral  Anesthesia" 
has  been  included. 

Arnold  Sturmdorf. 


CONTENTS. 


Page 
CHAPTER  I. 

General  Principles   3 

CHAPTER  n. 
Preoperative  and  Postoperati\'^  Periods  11 

CHAPTER  III. 
Sacral  Anesthesia  in  Gynecoplastic  Operations  17 

CHAPTER  IV. 
Tracheloplasty 26 

CHAPTER  V. 
Chronic  Endocervicitis 32 

CHAPTER  VI. 
Etiology  of  Endocervicitis 53 

CHAPTER  VII. 
Treatment  of  Chronic  Endocervicitis 58 

CHAPTER  VIII. 
The  Cervicoplastic  Treatment  of  Sterility  84 

CHAPTER  IX. 
Perineorrhaphy 88 

CHAPTER  X. 
The  Mechanism  of  Intrapelvic  Visceral  Support 93 

CHAPTER  XI. 

The  Levator  Ani  Muscle  109 

(v) 


vi  CONTENTS. 

Page 
CHAPTER  XII. 

The  Pelvic  Fascia • 115 

CHAPTER  XIII. 
Levator  Myorrhaphy 124 

CHAPTER  XIV. 

The  Retrodisplaced  Uterus  as  a  Complication  in  Pelvic  Floor 
Injury    ISO 

CHAPTER  XV. 
Cystocele  164 

CHAPTER  XVI. 
Operations  for  Cystocele  174 

CHAPTER  XVII. 
Laceration  Through  the  Anal  Sphinctre 198 

CHAPTER  XVIII. 
Vesicovaginal  Fistula  209 

CHAPTER  XIX. 
Operations  for  Vesicovaginal  Fistula  212 

CHAPTER  XX. 
Functional  Urinary  Incontinence 234 

CHAPTER  XXI. 
Exstrophy  of  the  Bladder  240 

CHAPTER  XXII. 
Fecal  Fistula  246 

CHAPTER  XXIII. 
Cancer  of  the  Vulva  252 

CHAPTER  XXIV. 
Elephantiasis  Vulv^  268 


COXTEXTS.  vii 

Page 
CHAPTER  XXV. 

Congenital  Malformations   275 

CHAPTER  XXVI. 
Malformations  of  the  Vagina  and  Vulva  291 

CHAPTER  XXVn. 
Operative  Correction  of  Congenital  Malformations  309 


LIST    OF    ILLUSTRATIONS. 


Fig.  Page 

1.  Separation  of  spinal  and  sacral  canals  (Gray-Spitska)    18 

2.  Coccygeal  vertebra  fused  with  sacrum   (Thompson)    20 

3.  Coccygeal  vertebra  fused  with  sacrum,  very  long  hiatus 21 

4.  Curved  type  of  sacrum   (Thompson)    22 

5.  Sacral  blocking,  areas  of  anesthesia,  etc 23 

6.  Normal  cervical  glands  33 

7.  Normal  endocervical  mucosa 34 

8.  Normal  cervical  gland  36 

9.  Normal  utricular  glands  of  the  corporeal  endometrium 37 

10.  Corporeal  endometrium   38 

11.  Automatic    contractions    of    uterine    muscle    four   hours    after 

hysterectomy   (Lieb)    39 

12.  Automatic  contractions  of  a  muscle  strip  from  a  non-pregnant 

uterus  three  hours  after  hysterectomy  (Lieb)    40 

13.  Sagittal  section  of  the  uterus  (Abel)   42 

14.  Periadnexal  lymphatics,  sheep's  uterus  (Leopold)    45 

15.  Distribution    and    course   of   the    periuterine    and    periadnexal 

lymphatics  (Color)    47 

16.  Periadnexal    adhesions   and   phlebectasia,   the    result  of   endo- 

cervicitis 49 

17.  Infantile  endocervicitis — "vulvovaginitis"    53 

18.  Chronic  endocervicitis,  section   from  a  cervix  after  cauteriza- 

tion (Abel)    54 

19.  Chronic  endocervicitis,  section  of  erosion  of  the  cervix  (Abel)  .  55 

20.  Infantile     erosion — "chronic     endocervicitis"      (Chrobak     and 

Rosthorn)    57 

21.  Chronic  endocervicitis  59 

22.  Chronic  endocervicitis,   round-cell  infiltration  in   sub-epithelial 

layers  60 

23.  Chronic  endocervicitis  with  miliary  abscess   61 

24.  Cancerous  endocervical  gland  (Abel)    62 

25.  Carcinoma  of  the  cervix  (Abel)    63 

26.  Advancing  carcinoma  of  cervix  65 

27.  Advanced  carcinoma   66 

28.  Tracheloplasty   (author's  method).     Outlining  the  edge  of  the 

flap  on  the  vaginal  sheath  of  the  cervix  67 

29.  Tracheloplasty    (author's   method).     Elevating  the   flap    edge 

preparatory  to  its  free  mobilization 68 

30.  Tracheloplasty   (author's  method).    Mobilization  of  the  cylin- 

drical vaginal  flap  70 

31.  Tracheloplasty    (author's   method).     Excision   of   endocervical 

cone    71 

32.  Tracheloplasty  (author's  method).    Denuded  funnel  of  cervical 

muscularis  72 

33.  Tracheloplasty    (author's   method).     Silkworm   strand  passed 

transversely  through  the  vaginal  surface   of  the  anterior 

flap  segment 74 

34.  Modified  Peaslee  needle  75 

35.  Tracheloplasty  (author's  method).     Introducing  the  right  free 

suture  end  into  and  above  the  internal  os  76 

(ix) 


X  LIST  OF  ILLUSTRATIONS. 

Fig.  Page 

36.  Tracheloplasty    (author's  method).     Needle  emerging  on  the 

anterior  vaginal  fornix   T] 

37.  Tracheloplasty     (author's    method).      Left    free    suture    end 

passed  upward  and  forward 78 

38.  Tracheloplasty    (author's  method).     Traction  on  the  two  an- 

terior suture  ends,  etc 80 

39.  Tracheloplasty    (author's    method).      Anterior    and    posterior 

sutures  drawn  taut  and  tied 82 

40.  Normal  nulliparous  vulva 94 

41.  Normal  parous  vulva.    Competent  levator  ani  muscle 95 

42.  Parous  vulva,  gaping  from  lacerated  levator  ani  muscle 96 

43.  Initial  direction  of  intra-abdominal  pressure  at  pelvic  brim  ....  102 

44.  Normal  pressure  deflection  by  the  intrapelvic  planes 106 

45.  Levator  ani  seen  from  below  {Dickinson)    110 

46.  Origin  of  the  left  anterior  loop  of  the  levator  ani  Ill 

47.  The  intra-pelvic  line  of  origin  of  the  levator  ani  (Haynes)   . . .  112 

48.  Levator  ani  fibres  normally  present  in  the  rectovaginal  septum.  113 

49.  Anatomy  of  the  female  perineum.    Superficial  area  116 

50.  The  pelvic  outlet  117 

51.  Anatomy  of  the  female  perineum.    Mid-area  118 

52.  The  levator  fascia 119 

53.  Anatomy  of  the  female  perineum.     Exposure  of  the  levator 

muscle  after  removal  of  the  levator  fascia  120 

54.  Anatomy  of  the   female  perineum.     Exposure   of  the  recto- 

vesical fascia  after  removal  of  the  levator  muscle 121 

55.  Perineoplasty  (avithor's  method)    125 

56.  Perineoplasty   (author's  method).     Flap  is  carefully  elevated 

from  the  underlying  layer 126 

57.  Elevating  the  vaginal  mucosa 127 

58.  Method  of  flap  dissection  128 

59.  Fascial  slits  for  levator  exposure 129 

60.  Incorrect  method  of  exposing  the  levator  muscle  130 

61.  Perineoplasty   (author's  method).     Suture  traction   132 

62.  Perineoplasty    (author's    method).      The    levator    ani    partly 

exposed  133 

63.  Perineoplasty  (author's  method).    The  sutures  passed  entirely 

round  (not  through)  the  muscle-shanks  134 

64.  Perineoplasty    (author's    method).      Levator    sutures    in.    situ 

and  tied 136 

65.  Perineoplasty  (author's  method).    The  elevated  flap  of  vaginal 

mucosa  is  not  ablated 138 

66.  Perineoplasty  (author's  method).    The  hollow  cone  of  vaginal 

mucosa  is  inverted  upon  itself  139 

67.  Perineoplasty     (author's     method).       Diagrammatic     sagittal 

section 140 

68.  Perineoplasty  (author's  method).    Sutures  introduced  to  unite 

the  musculofascial  layers  142 

69.  Diagram  of  the  vulvoperineal  musculature   143 

70.  Transverse  perinei  often  mistaken  for  the  levator  edge 144 

71.  Fascial  layers  in  relation  to  the  levator  ani  145 

72.  Incorrect  denudation 146 

73.  Incorrect  exposure  148 

74.  Normal  or  neutral  type  of  posture   152 

75.  Kangaroo  type  of  posture 153 

76.  Axis  of  abdominal  cavity,  axis  of  pelvic  cavity 155 

77.  Author's  method  of  determining  the  lumbar  index  157 


LIST  OF  ILLUSTRATIONS.  xi 

Fig.  P-^ge 

78.  Diagram  of  relation  of  pelvis  to  abdomen   158 

79.  Anterior  colpocele  simulating  cystocele    164 

80.  Urethrocele    .•  •  •   165 

81.  Inversion  of  the  vagina  with  cystocele  and  procidentia  uteri  . .    166 

82.  Initial  direction  of  intra-abdominal  pressure  at  pelvic  brim  . .    167 

83.  Misdirected  pressure  deflection  169 

84.  Perineal  laceration    170 

85.  Procidentia  uteri   171 

86.  Bladder  pillars   175 

87.  Operation    for    cystocele.      Exposure    of    the    bladder    pillars 

(rrank)   ' 176 

88.  Cystocele    operation.      Cervical    sutures    tied    holding   bladder 

(Frank)   177 

89.  Vaginal  hysterectomy,  ligature  of  uterine  artery  179 

90.  Vaginal  hysterectomy,  ligature  of  broad  ligament  187 

91.  Vaginal    hysterectomy,    ligature    of    the    utero-ovarian    artery 

and  tube  :  •   190 

92.  Vaginal  hysterectomy,  stumps  of  the  broad  ligament  seen  in 

the  wound   •  •  • 192 

93.  Broad  ligament  stumps  sutured  across  the  midline  (Goffe)   ...   194 

94.  Upper  free  end  of  ligaments  tied  (Goffe)    195 

95.  Complete  laceration  of  the  perineum  through  anal  sphinctre 

(Kelly) ...199 

96.  Warren-Ristine    operation    for    complete    perineal    laceration 

through  the  anal  sphinctre   201 

97.  Child's  outlining  apron  flap  in  the  Warren-Ristine  operation..  202 

98.  Warren-Ristine  operation   203 

99.  Child's  sutures  in  the  Warren-Ristine  operation   205 

100.  Cross-section  of  figure-of-eight  sutures  (Child)    206 

101.  Closure  of  bladder  fistula  with  buried  catgut  sutures  (Macken- 

rodt)   ; 213 

102.  Vesicovaginal  fistula.     Mackenrodt's  operation    214 

103.  Lateral  vaginoperineal  incision  ( Ward)    217 

104.  Schuchardt's  incision  outlined    (Ward)    219 

105.  Schuchardt's  incision  completed  (Ward)    221 

106.  Plane  of  Schuchardt's  incision   (Ward)    223 

107.  Mobilization  of  the  bladder  ( JVard)    224 

108.  Displacement  downward  of  the  bladder  (Ward)    226 

109.  Vaginal  suture  in  situ  ( Ward)   228 

110.  Exposure  and  suture  of  sphinctre  vesicae  (Frank)    229 

111.  Operation  for  incontinence  of  urine  235 

112.  Operation  for  urinary  incontinence 236 

113.  Kelly's  mattress  suture  237 

114.  Shortening  of  the  vesical  sphinctre  238 

115.  Operation  for  exstrophy  of  the  bladder  242 

116.  Operation    for   exstrophy   of   the   bladder.     Uretero-intestinal 

anastomosis  (Mayo)   243 

117.  Adenocarcinoma  of  the  left  vulvovaginal  gland  (Kelly)    253 

118.  Primary  carcinoma  of  clitoris   (^Taussig)    254 

119.  Lymphatics  of  the  external  genitalia  (Crossen)   255 

120.  The  lymphatics  of  the  urethra  and  vagina  (Crossen)    256 

121.  Regional  layer  dissection  of  vulvar  structures   258 

122.  Regional  layer  dissection  of  the  vulvar  structures 260 

123.  Outlines    for    the   "block    excision"    of    the    external    genitals 

(Crossen)     261 

124.  First  step  in  the  "block  excision''  (Crossen)    262 


xii  LIST  OF  ILLUSTRATIONS. 

Fig.  Page 

125.  The  block  of  tissue  partially  excised  (Crossen)   263 

126.  Denuded  area  after  removal  of  inguinal  glands 264 

127.  Block  excision,  wound  closed   (Color)    266 

128.  Elephantiasis  (Stein)   270 

129.  The  rudimentary  sexual  ducts   (Adami)    276 

130.  The   indifferent   stage   in   the    development   of   the   generative 

organs   (Piersol)    277 

131.  Development  of  the  female  generative  organs   {Piersol)    278 

132.  Development  of  the  male  generative  organs  (Piersol)   279 

133.  Double  uterus  (Mann)   283 

134.  Bicornate  uterus 284 

135.  Left  tube,  ovary  and  uterine  nodule  (Kelly)   285 

136.  Double  uterus, 'vagina  and  planiform  fundus   (Kelly)    286 

137.  Pregnancy  in  a  rudimentary  left  uterine  horn  (Color)   (Kelly).  288 

138.  Development  of  the  external  genitals    294 

139.  Anus  vulvalis  (After  Dwight)    296 

140.  Pseudohermaphroditism   (After  Poszi)    297 

141.  Agglutination  of  the  labia  299 

142.  Atresia  of  the  vulva  (Stilton  and  Giles) 302 

143.  Atresia  of  the  vagina  (Sulton  and  Giles)    303 

144.  Feminine  pseudohermaphroditism   305 

145.  Agglutination  of  the  labia,  after  division  of  the  membrane  . .  .  310 

146.  Widening  the  vaginal  opening  for  dyspareunia  (Crossen)    312 

147.  Forming  an  artificial  vagina   314 

148.  Intestinal  resection  for  artificial  vagina   316 

149.  Intestinal  resection,  the  intestinal  loop  in  place   318 

150.  Artificial  vagina  from  a  section  of  the  rectum  319 

151.  Artificial  vagina,  traction  being  made  on  the  gauze  strip  320 

152.  Artificial  vagina,  later  steps  in  the  operation  321 


LIST    OF    PLATES. 


Plate  Facing  page 

I.     Chronic  endocervicitis  (Palmer  Fiiidlcy)   32 

II.     Injection  specimen,  normal  nulliparous  uterus,  transverse 

section  of  myometrium  (Leopold)    44 

Transverse  section  of  uterine  muscle  44 

III.  Chronic  interstitial  myometritis — "fibrosis  uteri"  48 

IV.  Histopathology  of  "cervical  erosion"  56 

V.     Healed  non-infected  bilateral  laceration  64 

Mild  endocervicitis,  bilateral  laceration 64 

VI.     Virginal  chronic  endocervicitis    64 

VII.     Virginal  chronic  endocervicitis  with  "erosion"  64 

Chronic    endocervicitis    with    mild    manifestation    at    the 

external  os 64 

VIII.    A.  Gonorrheal  condylomata 64 

B.  Gonorrheal  endocervicitis 64 

IX.     Chronic  endocervicitis  64 

Chronic  endocervicitis,  mild  infection  64 

X.     Chronic  endocervicitis — "papillary  erosion"  64 

Chronic  endocervicitis,  infected  laceration  64 

XI.     Chronic  endocervicitis.  infected  laceration  with  "ulceration 

and  suppurative  nabothian  folliculitis"  64 

Chronic  endocervicitis,  infected  laceration,  "ectropium  with 

follicular  suppuration"  ' 64 

XII.     Chronic  endocervicitis,  infected  laceration  with  "granular 

erosion"  and  nabothian  folliculitis  64 

Chronic  endocervicitis,  with  mucous  polypi   64 

XIII.  Chronic  endocervicitis,  with  carcinomatous  papilloma  ....  64 
Endocervical  carcinoma  in  the  initial  stage  64 

XIV.  Chronic  endocervicitis,  with  carcinomatous  ulceration  ....  64 
Carcinoma   of   cervix   with    sloughing  into    the   posterior 

vaginal  vault 64 

XV.     Carcinoma  of  cervix,  with  endocervical  necrosis   64 

Endocervical  carcinoma  in  section   64 

XVI.     Syphilitic  ulcer  in  angle  of  laceration 66 

XVII.     Tracheloplasty   (author's  method)    68 

XVIII.     Tracheloplasty  (authors  method),  schematic  sagittal  view 

of  the  suture  course  in  the  anterior  flap  segment 80 

XIX.     Arterial  supply  of  the  perineal  region 128 

XX.     Complete  perineal   laceration  through  the  anal  sphinctre, 

with  exposure  of  the  posterior  vaginal  and  rectal  walls.  196 

XXI.     Circumscribed  epithelioma  of  the  vulva  254 

Diffuse  ulcerative  epithelioma  of  the  vulva 254 

XXII.     Elephantiasis  of  the  vulva 268 

XXIII.     Syphilitic  gummata 272 

(xiii) 


INTRODUCTORY. 


Gynecology  is  in  the  dawn  of  a  new  era;  its 
operative  technology  is  slowly  emerging  from  em- 
pirical formularies  into  rational  procedures  based 
upon  fundamental  factors  established  by  modern 
research. 

Current  investigations  of  surgical  "end  results," 
while  as  yet  in  their  initiative,  have  already  demon- 
strated that  healed  incisions  and  purely  objective 
restitutions  to  hypothetical  normals  do  not  prove  the 
cure — plastic  reconstructions  as  such  do  not  restore 
functions,  and  a  symptomologic  nosology  does  not 
convey  a  diagnosis. 

Concept  dominates  practice.  We  were  taught  to 
see  a  passive  retention  wedge  in  the  "perineal  body" 
where  we  must  recognize  an  active  myodynamic  de- 
flector of  intra-abdominal  pressure  in  the  levator  ani 
muscle. 

The  "law  of  deflection"  applied  to  the  dynamics  of 
that  elusive  force — intra-abdominal  pressure — clari- 
fies the  problems  of  normal  and  abnormal  uterine 
poise;  it  reveals  the  nature  of  congenital  retro-posi- 
tions as  compensatory  static  deviations,  normal  to  cer- 
tain types  of  skeletal  contour  in  which  the  multifa- 
rious corrective  operations  upon  the  uterine  ligaments 
should  be  relegated  to  the  limbo  of  the  obsolete. 

The  time  has  passed  when  the  term  "endometritis" 
encompassed  the  beginning  and  end  of  uterine  path- 
ologv — when  "reflex  neurosis"  presented  the  shibbo- 

(1) 


2  INTRODUCTORY. 

leth  of  its  general  symptomatology,  and  curettement 
the  slogan  of  its  therapy. 

Kundrat  in  1873  exposed  "endometritis"  as  a  nor- 
mal premenstrual  manifestation  in  pathological  guise. 

Leopold  in  1874  blazed  the  path  to  a  rational 
uterine  pathology  by  depicting  the  myometrial  lymph 
course;  and  Henricius  in  1889  unwittingly  revealed  a 
fundamental  factor  in  uterine  physiology  by  demon- 
strating that  the  normal  no^-gravid  uterus  is  a  rhyth- 
mically contracting  organ. 

More  recently,  Hertoghe's  observations  on  hypo- 
thyroidism established  an  endocrine  pathogenesis  in 
the  category  of  metrorrhagias;  and  Rosenow  suc- 
ceeded in  tracing  the  metastatic  habilitation  of  bac- 
teria within  the  ovarian  tissues  from  distal  latent  foci. 

The  biochemic  factors  evolved  by  these  latter  re- 
searches illumine  the  haze  of  the  "reflex  neuroses," 
in  which  we  begin  to  discern  lineaments  of  insidious 
sepsis  and  toxicosis. 

These  specific  phases  of  established  validity  and 
far-reaching  significance  are  elucidated  in  a  widely 
scattered  literature,  which  has  not  yet  been  correlated 
to  that  concrete  homogeneity  essential  to  their  more 
general  dissemination  and  practical  application. 

This  is  conspicuously  evident  in  the  current  text- 
book chapters  on  the  cervix  and  perineum. 


CHAPTER  I. 

General  Principles. 

Preliminary  to  the  special  technology  of  the 
various  operations  about  the  vulvovaginal  tract,  it 
is  essential  to  dwell  upon  certain  general  principles 
which  apply  to  the  preoperative,  operative,  and  post- 
operative stages  of  gynecoplastic  procedures  as  a 
class. 

The  majority  of  these  procedures  are  essentially 
multiple,  necessitating  prolonged  anesthesia  and  ex- 
tensive denudations  of  vascular  areas  in  a  more  or 
less  contaminated  field.  Prolonged  anesthesia  and 
extensive  denudation  of  vascular  areas  in  a  con- 
taminated field  obviously  embody  elements  of  seri- 
ous potentialities  which  are  too  frequently  disre- 
garded in  this  branch  of  surgery. 

The  success  of  a  gynecoplastic  operation  de- 
pends not  only  upon  the  technical  skill  of  the  opera- 
tor, but  upon  his  clinical  ability  to  estimate  in  a 
given  case  the  local  and  systemic  factors  that  w^ill 
dominate  the  immediate  and  remote  efifects  of  his 
surgical  procedure. 

Gynecoplasty  is  elective  surgery,  and,  as  such, 
affords  ample  time  to  determine  the  presence  of  the 
local,  visceral,  or  systemic  complications  that  would 
tend  to  jeopardize  the  operative  outcome. 

Minor  degrees  of  shock,  hemorrhage,  and  infec- 
tion, ordinarily  negligible,  are  nevertheless  insep- 
arable  from    the   major    surgery   of   the    urogenital 

(3) 


4  GYNECOPLASTIC   TECHNOLOGY. 

region;  and  while  no  surgeon  can  predicate  with 
any  approach  to  accuracy  a  patient's  inherent  resist- 
ance, he  can,  and  should,  eliminate  or  minimize  most 
of  the  factors  that  tend  to  enhance  the  gravity  of 
these  morbid  concomitants. 

Omitting  a  categorical  elucidation  of  the  gross 
organic  disorders  which  constitute  obvious  contra- 
indications to  surgical  measures,  it  is  essential  to 
indicate  the  more  insidious  pathological  factors  that 
frequently  predetermine  the  operative  and  postoper- 
ative morbidity. 

Crile  states:  ''A  good  heart  and  normal  blood- 
vessels, with  active  innervation,  and  with  the  capa- 
bility of  maintaining  an  average  blood-pressure,  give 
the  patient  a  strong  defense  against  operative  trau- 
matism. With  almost  human  ingenuity,  however, 
disease  processes  strike  at  the  strongest  defenses  of 
their  intended  victim,  and,  as  a  consequence,  all  too 
seldom  does  a  patient  come  to  the  surgeon  with  this 
protective  mechanism  unimpaired. 

"It  is  essential,  then,  that  we  understand  well  the 
causes  which  may  produce  menacing  deviations  in 
blood-pressure,  that  we  may  be  able  to  combat  suc- 
cessfully these  conditions  by  preliminary  and  coinci- 
dent measures." 

Hypertension  may  be  but  a  temporary  condition 
induced  by  a  continued  and  intense  emotion — worry, 
grief,  or  anger.  It  may  be  due  to  acute  or  chronic 
infection,  to  exophthalmic  goitre,  or  to  increased  in- 
tracranial pressure,  as  well  as  to  such  more  immediate 
causes  as  cardiovascular  disease  and  physical  changes 
in  the  blood-vessel  walls.  From  this  enumeration  it  is 
obvious  that,  while  some  of  the  causes  of  hypertension 


GENERAL    PRINCIPLES.  5 

are  temporary  and  remediable,  others  are  permanent 
and  irremediable. 

In  estimating,  therefore,  the  surgical  risk  in  a 
patient  with  hypertension,  it  is  essential  to  differen- 
tiate the  remediable  from  the  irremediable  class,  elimi- 
nating the  operative  hazard  in  the  former,  and 
reducing  it  in  the  latter,  by  resort  to  palliation  until 
an  approximation  to  normal  vascular  tension  is  in- 
duced by  appropriate  measures. 

Gynecological  patients  range  from  the  adolescent 
to  the  senile;  their  different  disorders  embody  all  the 
etiological  factors  of  abnormal  circulatory  pressure — 
senescent  arteriosclerosis;  severe  anemia,  secondary 
to  menorrhagia  or  metrorrhagia;  chronic  toxemia, 
from  infectious  foci  in  the  cervix  or  tubes;  renal 
involvement,  especially  in  cases  of  marked  cystocele 
with  retention. 

The  hormonic  influence  of  the  ovaries  on  vascular 
tension  is  clinically  evidenced  during  menstruation 
and  the  climacteric,  while  emotional  states  and  gen- 
eral psychic  erethism  are  characteristic  concomitants 
of  gynecic  disorders. 

A  superposed  element  of  danger  in  operating  upon 
patients  with  hypertension  is  the  anesthetic.  Ether, 
however  skilfully  controlled,  induces  psychic  stress  in 
the  primary  stage  of  its  administration.  It  impairs 
the  immunity  of  the  patient ;  it  retards  the  coagulation- 
period  of  the  blood;  as  a  fat  solvent  it  disintegrates 
many  of  the  body  lipoids,  especially  those  in  the  brain, 
the  renal  epithelium,  and  the  liver,  with  consequent 
increase  in  waste  products,  and  augmented  tax  upon 
the  excretory  organs. 

The  strain  of  ether  nausea  and  vomiting,  always 


6  GYNECOPLASTIC   TECHNOLOGY. 

a  disturbing  feature,  is  especially  so  in  cases  of  hyper- 
tension. Therefore,  its  administration  in  these  cases 
must  be  reckoned  as  a  distinct  risk  per  se,  because  it 
injures  and  taxes  the  kidneys,  predisposes  to  embolism 
and  pneumonia,  and  intensifies  the  traumatic  and 
psychic  dangers, 

A  class  of  patients  particularly  prone  to  shock 
and  infection  are  those  presenting  severe  secondary 
anemias  of  recent  origin,  frequently  found  among  the 
adolescent  and  preclimacteric  metrorrhagiacs,  in  none 
of  which  should  any  operative  procedure  be  under- 
taken when  the  hemoglobin  has  fallen  to  50  per  cent, 
of  the  normal. 

As  operative  risks,  the  heart,  the  kidneys,  and 
blood-pressure  are  so  intimately  correlated  that  they 
may  be  discussed  collectively. 

The  presence  of  cardiac  murmurs  or  enlargement 
of  the  heart  is  readily  determined. 

Cardiac  hypertrophy  with  valvular  lesions  will 
withstand  an  operative  strain  better  than  a  heart  that 
is  apparently  normal  in  size  without  such  lesions,  but 
with  a  weakened  or  dilated  myocardium. 

The  relative  range  of  the  systolic  and  diastolic 
blood-pressure  presents  an  approximate  index  of  the 
myocardiac  and  vascular  tonicity. 

The  blood-pressure  should  be  noted  before,  during, 
and  after  every  extensive  operation  as  a  gauge  of  the 
patient's  resistance  to  the  anesthetic  and  surgical 
trauma.  A  sudden  drop  in  the  systolic  pressure  is  a 
danger  signal. 

The  normal  systolic  pressure,  taken  with  the  10 
or  12  cm.  cuff,  ranges  from  no  to  140  mm.  of  mer- 
cury, the  diastolic  running  from  20  to  40  mm.  lower. 


GENERAL    PRINCIPLES.  7 

The  normal  pulse  may  affect  the  normal  pressure. 
A  pulse  under  65  gives  about  123  mm.,  and  over  85, 
130  mm.  Transitory  rise  may  occur  from  apprehen- 
sion, requiring  a  second  or  third  reading.  It  will  rise 
after  eating  and  drinking,  persisting  for  nearly  an 
hour.  Exercise  will  augment  it  from  5  to  15  mm.  A 
very  low  blood-pressure  (100  mm.  of  mercury)  in  an 
adult  denotes  a  weak  heart. 

A  persistent  blood-pressure  exceeding  140  should 
suggest  a  possible  arteriosclerotic  or  renal  menace. 

There  are  various  indirect  methods  of  testing  the 
functional  capacity  of  the  heart;  the  simplest  is  to 
note  the  relative  pulse-rate  in  different  attitudes — 
sitting,  standing,  lying — or  its  increased  rapidity  on 
slight  exertion. 

Normally,  on  assuming  the  recumbent  posture,  the 
pulse  becomes  slower. 

If  the  patient  is  recumbent,  rising,  or  even  turning, 
will  reveal  abnormal  cardiac  strain.  If  the  pulse 
rapidity  is  greatly  increased,  and  lasts  more  than  a 
few  minutes,  the  heart  is  defective. 

A  m'inary  examination  of  the  twenty-four-hour 
specimen,  with  the  patient  on  full  diet,  should  reveal 
not  only  the  presence  of  albumin,  casts,  sugar,  the 
estimated  excretion  of  nitrogen  and  the  more  impor- 
tant inorganic  salts,  but  also  the  permeability  of  the 
kidneys  as  demonstrated  by  aniline  tests. 

Under  normal  conditions,  blue  urine  is  excreted  in 
ten  to  twelve  minutes  after  an  intramuscular  injec- 
tion of  4  mils  of  a  4  per  cent,  indigo-carmine  solution. 

Any  marked  delay  in  the  color  excretion  denotes 
a  renal  impairment. 

If  nephritis  is  present,  or  if  an  insidious  intersti- 


8;  GYNECOPLASTIC   TECHNOLOGY. 

tial  nephritis  is  suspected,  the  operative  prognosis, 
especially  under  prolonged  anesthesia,  is  serious; 
such  kidneys  may  readily  cease  functioning. 

If  the  blood-pressure,  the  strength  of  the  heart, 
and  the  kidney  efficiency  approximate  the  normal,  the 
prognosis  from  these  points  of  investigation  is  clear. 

When  the  kidneys  are  but  slightly  involved,  a  short 
period  of  carbohydrate  diet,  with  rest  in  bed  and 
liberal  intake  of  water,  will  minimize  the  danger  of 
uremia,  acetonuria,  or  acidemia. 

An  equally  vital  consideration  is  the  condition  of 
the  gastro-intestinal  function.  The  presence  of  such 
conditions  as  dilated  stomach,  motor  impairment,  in- 
testinal stasis  with  impacted  feces,  may  induce  the 
absorption  of  putrefactive  and  fermentative  toxins, 
all  of  which  demand  preoperative  correction. 

Prolonged  starving  of  a  patient  for  from  twenty- 
four  to  forty-eight  hours,  and  profuse  purging  with 
more  or  less  drastic  cathartics,  are  not  to  be  com- 
mended as  rational  preparatory  treatment. 

These  measures  cleanse  the  gastro-intestinal  tract, 
while  they  deplete  the  patient's  strength  and  re- 
sistance. 

The  preferable  method  is  to  administer  mild  pur- 
gatives of  the  vegetable  class  for  several  days  pre- 
vious to  the  operation,  thus  giving  the  intestine  time 
to  regain  its  normal  activity  without  debilitating  the 
patient. 

For  twenty-four  hours  before  an  operation  the 
patient's  diet  should  consist  mainly  of  simple  carbo- 
hydrates. The  greater  the  quantity  of  such  nutri- 
ment assimilated,  the  less  danger  from  excessive  post- 
operative vomiting,  acetonuria,  or  fatal  acidemia. 


GENERAL    PRINCIPLES.  9 

Hospital  surgeons  generally  prefer  to  operate 
during  the  early  morning;  in  such  instances  the  pa- 
tient has  probably  fasted  for  from  twelve  to  fourteen 
hours. 

While  under  ordinary  conditions  an  individual  is 
at  his  lowest  temperature,  lowest  blood-pressure,  and 
lowest  cardiovascular  tone  from  four  o'clock  to  eight 
in  the  morning,  there  is  on  the  other  hand  a  decided 
advantage  in  operating  upon  a  patient  who  has  en- 
joyed a  good  night's  sleep,  free  from  the  depressing 
influence  of  anxious  anticipations. 

Other  things  being  equal,  it  may  be  well  in  the 
majority  of  cases  to  operate  during  the  morning 
hours,  provided,  however,  that  the  patient  has  received 
some  stimulating  nourishment,  such  as  a  cup  of  coffee 
or  tea  with  sugar  but  without  milk,  two  hours  pre- 
vious to  the  operation. 

The  caffein  in  the  coffee  will  temporarily  raise  the 
blood-pressure.  This  is  especially  desirable  when  the 
circulatory  apparatus  had  gradually  adapted  itself, 
through  a  long  period,  to  increased  vascular  tension, 
the  sudden  diminution  of  which  may  induce  an  acute 
cardiac,  respiratory,  or  cerebral  failure. 

Thyrotoxicosis,  especially  of  the  more  insidious 
type,  is  a  frequent  complication  of  gynecic  disorders. 
A  rapid  heart  may  present  the  only  symptom  of  this 
condition,  in  which  postoperative  shock,  or  so-called 
"delayed  shock,"  should  be  anticipated.  In  very  mild 
or  suspicious  cases  it  may  be  wise  to  administer  a 
hypodermatic  injection  of  morphine  before  operating. 

As  a  routine  practice,  however,  the  preoperative 
administration  of  morphine  or  scopolamine  is  not  to 
be  commended.     It  is  generally  recognized  that  in 


10  GYNECOPLASTIC   TECHNOLOGY. 

marked  hyperthyroidism  surgery  should  be  postponed 
until  general  measures  have  mitigated  the  toxicity  of 
the  excessive  thyroid  secretion. 

The  sleeping  habits  of  the  patient  will  repay  in- 
vestigation. A  woman  who,  from  anxiety  or  other 
cause,  has  not  slept  for  days  or  weeks  prior  to  an 
operation,  will  not  do  so  without  medication  after 
such  operation;  a  succession  of  sleepless  nights  will 
not  tend  to  conserve  her  mental  and  physical  stamina 
for  the  operative  ordeal.  A  mild  hypnotic  is  therefore 
indicated  in  all  such  cases  during  the  preparatory 
period,  and,  while  generally  objectionable  as  a  routine 
practice,  it  will  obviate  the  necessity  for  the  exhibition 
of  stronger  narcotics  during  the  postoperative  stage  in 
women  of  this  class. 

The  premenstrual  and  menstrual  period  are  un- 
favorable to  gynecoplastic  surgery,  for,  aside  from 
obvious  objections,  the  functional  hypersemia  and  the 
presence  of  an  active  anticoagulative  substance  in  the 
menstrual  blood  may  induce  a  very  copious  oozing 
during  operation,  and  enhance  the  possibility  of  post- 
operative hemorrhage. 

Finally,  an  active  gonorrhea,  cystitis,  vulvar 
eczema,  excoriations,  dermatitis  or  furunculosis 
should  be  eliminated  before  attempting  any  plastic 
procedure  about  the  urogenital  canal. 

In  all  cases  of  complete  procidentia  of  long  stand- 
ing it  is  advantageous  to  replace  and  retain  the  pro- 
lapsed organs  mechanically,  while  confining  the  pa- 
tient to  bed  for  at  least  four  days  prior  to  operation. 

If  the  cervix  presents  infected  ulcerations,  these 
should  be  previously  cauterized. 


CHAPTER  II. 

Preoperative  and  Postoperative  Periods. 

The  older  gynecologists  invariably  subjected  their 
patients  to  a  very  protracted  preoperative  routine,  ex- 
tending in  some  instances  over  several  months,  w^hile 
modern  gynecologists  generally  operate  within  a 
twenty-four-hour  preparatory  interval. 

All  routine  practice  is  bad  practice;  protracted 
meddling  is  superfluous.  On  the  other  hand,  inade- 
quate precautions  are  dangerous  pitfalls.  Every  case 
presents  its  own  specific  indications,  which  should  be 
met  to  the  smallest  detail. 

Repeated  copious  irrigation  of  the  vaginal  canal 
for  disinfecting  purposes  should  be  restricted.  The 
vaginal  lining  is  generally  regarded  as  incapable  of 
absorbing  pharmacologic  agents ;  nevertheless,  numer- 
ous cases  of  mercuric  chloride,  zinc  sulphate,  iodo- 
form, arsenic,  belladonna  and  phenol  poisoning  are 
recorded  as  the  result  of  medicated  douches  and  local 
applications. 

The  studies  of  D.  I.  Macht  ''On  the  Absorption  of 
Drugs  and  Poisons  Through  the  Vagina,"  published 
in  the  Journal  of  Pharmacology  and  Experimental 
Therapeutics,  1918,  make  it  evident  that  "alkaloids, 
inorganic  salts,  esters  and  antiseptics  are  readily  ab- 
sorbed by  the  vaginal  mucosa,"  and  he  concludes  "that 
systemic  poisoning  of  obscure  origin  may  find  its  ex- 
planation in  absorption  of  toxic  agents  through  con- 
tact with  the  vagina." 

(11) 


12  GYNECOPLASTIC   TECHNOLOGY. 

On  the  afternoon  or  evening  before  operation  the 
external  genitals  and  adjacent  surfaces  are  shaved, 
and  the  patient's  lower  bowel  irrigated. 

This  obviates  the  necessity  of  disturbing  the  pa- 
tient's rest  in  the  early  morning.  All  local  prepara- 
tions should  be  completed  at  least  half  an  hour  before 
operating. 

With  the  anesthetized  patient  on  the  operating 
table,  the  genitalia,  the  vaginal  canal,  and  the  sur- 
faces surrounding  the  operative  field  are  scrubbed 
thoroughly  but  gently  with  green  soap,  warm  sterile 
water,  and  gauze  mops. 

The  soap  is  rinsed  off,  and  the  surfaces  thoroughly 
dried  with  sterile  towels,  after  which  the  bladder  is 
emptied  with  a  glass  catheter,  the  tip  of  which  is  pre- 
viously dipped  in  20  per  cent,  argyrol  solution. 

Two  per  cent,  tincture  of  iodine  may  then  be 
freely  applied  to  all  parts,  the  excess  being  dried  by 
gauze  sponges. 

Ease  of  accessibility  and  perfect  exposure  of  the 
operative  field  must  be  secured  as  prerequisite  essen- 
tials to  accurate  reconstruction,  every  step  of  which 
must  be  conducted  with  deliberation  and  painstaking 
attention  to  details. 

Anything  like  an  attempt  at  speed  in  plastic  work 
denotes  the  self-consciousness  of  the  operator  rather 
than  his  actual  skill  in  this  special  branch  of  surgery. 
At  the  end  of  each  operation  the  whole  field  should  be 
scrupulously  inspected  to  assure  the  correctness  of  ap- 
proximations, the  absence  of  undue  tension,  the  con- 
trol of  all  bleeding,  and  the  obliteration  of  dead 
spaces. 

Bleeding  vessels  should  be  clamped  without  crush- 


PREOPERATIVE  AND  POSTOPERATIVE  PERIODS.       13 

ing  surrounding  tissues,  the  finest  catgut  being  used 
for  ligation. 

Rigid,  scarred,  non-vascular  or  inflamed  and 
oedematous  tissues  are  useless  for  plastic  purposes. 
All  flaps  should  consist  of  well-nourished  segments, 
neither  redundant  nor  inadequate,  permitting  of  nat- 
ural coaptation  without  stretching. 

Not  only  tight  sutures,  but  multiple  sutures,  are 
to  be  avoided. 

Figure-of-eight  stitches  are  undesirable  in  perineo- 
plasty. The  various  layers,  exhibiting  diflferent  de- 
grees of  resistance,  demanding  different  degrees  of 
tension,  cannot  be  controlled  in  any  figure-of-eight 
stitch,  the  deep  loop  frequently  proving  too  loose  or 
too  tight  for  the  superficial  loop. 

No  line  of  union  should  be  sewn  hermetically,  but 
minute  spaces  left  between  interrupted  stitches  to 
obviate  the  retention  of  blood-clots  and  preclude 
infection. 

It  is  safer  to  harbor  bacteria  in  dry  open  spaces 
than  in  closed  cavities  filled  with  decomposing  blood. 

In  the  postoperative  stage  the  immediate  dangers 
are  shock  and  postoperative  hemorrhage;  the  more 
remote  danger  is  infection.  All  three  are  better  pre- 
vented than  cured. 

The  anesthesia  should  be  discontinued  at  the 
earliest  feasible  moment.  The  margin  of  safety  in  the 
anesthesia  is  frequently  passed  during  the  final  stage 
of  the  operation. 

The  proximity  of  the  bowel  and  bladder  complicate 
the  problem  of  wound  dressings  about  the  vulvar 
region. 

All  intravaginal  douches  are  interdicted  during 


14  GYNECOPLASTIC   TECHNOLOGY. 

the  healing  period,  the  parts  being  kept  as  dry  as  pos- 
sible. This  is  best  accomplished  with  sterile  pads  dur- 
ing the  oozing  period,  after  which  all  dressings  are 
discarded,  and  the  parts  kept  dusted  thoroughly  with 
a  mixture  of  stearate  of  zinc  and  boric  acid.  The 
great  advantage  of  this  stearate  mixture  is  that  it 
sheds  water;  and,  while  it  may  gradually  become 
moist,  it  is  possible,  with  reasonable  care,  to  main- 
tain a  sufficient  degree  of  dryness  and  comfort.  This 
treatment  is  especially  advantageous  in  obese  patients 
with  closely  apposed  buttocks. 

Barring  cases  of  urinary  fistulse,  all  patients 
should  be  encouraged  to  void  voluntarily.  When 
necessary,  the  catheter  may  be  used  every  eight  hours, 
its  sterile  tip  being  invariably  dipped  into  and  filled 
with  20  per  cent,  argyrol  solution  prior  to  introduc- 
tion. The  necessary  resort  to  catheterization  is  the 
signal  for  the  internal  administration  of  urotropin,  5 
to  7^  grains  t.i.d. 

In  fistula  operations  demanding  rubber  retention 
catheters,  urotropin  should  be  avoided,  as  its  elimina- 
tion in  the  urine  will  disintegrate  the  catheter,  de- 
positing particles  of  rubber  or  the  entire  catheter  bulb 
within  the  bladder. 

The  sovereign  remedy  for  shock  is  morphine  in 
i/^ -grain  doses  by  hypo,  every  four  hours,  with  cam- 
phor in  sterile  oil  or  caffein  as  a  temporary  adjuvant. 
Strychnine  is  always  useless,  and  occasionally  harmful. 

The  amount  of  urine  secreted  is  the  most  practical 
guide  to  the  circulatory  condition  of  the  patient.  The 
more  nearly  this  amount  approximates  150  grams  per 
day  in  a  previously  normal  condition  the  safer  the 
patient. 


PREOPERATIVE  AND  POSTOPERATIVE  PERIODS.       15 

Albumin  and  casts  are  found  in  the  urine  so  fre- 
quently after  etherization  that  they  may  almost  be 
expected,  especially  the  albumin  after  prolonged 
operations. 

The  amount  varies  from  a  faint  trace  to  consider- 
able quantities.  The  profuse  perspirations  occurring 
during  operation,  the  nausea,  vomiting,  and  the  small 
amounts  of  fluids  ingested  previously,  depress  urinary 
excretion. 

The  greater  the  amount  of  urine  excreted,  the 
greater  the  elimination  of  toxins;  hence  the  patient 
should  receive  water  as  soon  as  possible  by  mouth, 
rectum,  or  hypodermoclysis. 

After  the  effects  of  the  anesthetic  have  passed, 
there  should  be  no  restriction  as  to  the  amount  of 
liquid  taken  by  the  patient.  A  few  sips  of  water  are 
given  at  first.  If  these  are  retained,  the  quantity  is 
rapidly  increased,  so  that  within  twenty-four  to  forty- 
eight  hours  at  least  three  pints  of  fluid  should  be  in- 
gested daily.  The  necessity  for  fluids  is  especially 
urgent  in  those  who  have  lost  much  blood,  and  in 
toxic  patients.  A  cup  of  coffee  or  tea  may  be  safely 
given  within  four  hours  after  the  operation,  provided 
there  is  no  nausea  or  vomiting.  After  the  first  post- 
operative bowel  movement,  full  diet  is  permissible. 

Excessive  and  prolonged  vomiting  should  be  com- 
bated promptly  by  stomach  lavage,  which  is  more 
especially  indicated  in  the  early  stages  of  acute  gastric 
dilatation. 

Unless  there  is  much  discomfort  from  flatus  or 
distention,  it  is  not  necessary  to  administer  laxatives 
for  the  first  three  or  four  days. 


16     ,  GYNECOPLASTIC   TECHNOLOGY. 

Enemata  are  objectionable,  as  they  tend  to  con- 
taminate the  adjacent  surgical  area. 

The  tendency  of  a  deficient  heart  to  acute  post- 
operative dilatation  should  prompt  caution  in  first 
directing  the  patient  to  assume  the  upright  position. 
The  elevation  should  be  very  gradual,  approaching  the 
vertical  when  the  blood-pressure  has  resumed  and 
maintained  the  level  normal  to  the  individual  as  estab- 
lished by  preoperative  observation. 


CHAPTER  III. 

Sacral  Anesthesia  in  Gynecoplastic 
Operations. 

Among  the  various  methods  and  means  for  the  in- 
duction of  regional  anesthesia,  the  one  most  appHcable 
and  uniformly  efficacious  in  gynecoplastic  surgery  is 
''sacral  blocking"  or  "caudal  anesthesia"  by  extra- 
dural novocain  injection. 

The  epidural  space  surrounding  the  dura  mater 
from  the  foramen  magnum  to  the  hiatus  sacralis  com- 
prises the  area  between  the  dura  mater  and  the  perios- 
teum lining  the  spinal  canal. 

The  sacral  canal  is  a  continuation  of  the  spinal 
canal,  but  at  the  second  sacral  segment  communication 
between  these  two  parts  is  interrupted  by  the  closure 
of  the  dura  mater  around  the  nerve  trunks. 

This  isolation  of  the  sacral  from  the  spinal  canal 
is  demonstrable  anatomically  (see  illustration). 
Laewen  showed  that  colored  fluids  injected  into  the 
sacral  canal  never  appeared  in  the  spinal  canal  or 
stained  the  upper  part  of  the  cord,  thus  proving  the 
absolute  isolation  of  these  two  sections  of  the  dural 
area  from  one  another,  so  that,  while  the  nerves  are 
transmitted  from  the  spinal  into  the  sacral  canal,  there 
is  no  other  communication  between  the  two.  This 
marks  the  distinction  between  sacral  and  spinal  anes- 
thesia; in  the  former,  the  anesthetizing  fluid  is  in- 
jected through  the  hiatus  sacralis  into  the  sacral  canal, 

2  (17) 


18 


GYNECOPLASTIC   TECHNOLOGY. 


while  in  the  latter  the  injection  is  made  through  the 
lumbar  origin  into  the  spinal  canal. 

Upon  the  outer  surface  of  the  dura,  in  the  epi- 
dural space,  especially  at  the  sides,  are  extensive 
venous  plexuses  and  loose  adipose  tissue. 


Fig.  1. — Showing  separation  of  spinal  and  sacral  canals  by  closure 
of  dura  mater.    Sacral  nerves  exposed.     (Gray-Spitska.) 


The  sacral  canal  terminates  below  in  the  hiatus 
sacralis,  forming  a  triangular  opening,  the  sides  of 
which  are  marked  by  the  bony  ridges  known  as  the 
sacral  cornua. 

This  opening  varies  in  size  in  different  individuals. 
It  may  be  abnormally  large,  owing  to  a  deficiency  in 


SACRAL  ANESTHESIA.  19 

one  or  more  of  the  vertebral  arches,  or  it  may  be  re- 
duced even  to  the  extent  of  complete  obliteration  by 
ossification. 

Normally,  the  hiatus  is  closed  by  the  posterior 
sacrococcygeal  ligament,  which  may  be  recognized  on 
palpation  by  passing  the  finger  along  the  sacral  spines 
from  above  downward. 

Laewen  has  aptly  compared  the  palpatory  charac- 
ter of  this  membrane  with  its  bony  borders  to  that  of  a 
fontanel. 

TccJuiiquc  of  Adiiiiiiisfrafioti.  The  patient  is 
placed  on  her  right  side,  on  an  inclined  surface,  w^ith 
head  elevated  and  the  spine  flexed  to  the  limit  of  com- 
fortable tolerance,  bringing  the  knees  and  chin  as 
nearly  together  as  possible. 

The  area  over  the  sacrum  and  the  immediate 
neighborhood  is  cleaned  with  benzine,  dried,  and 
painted  with  iodine. 

The  sacral  hiatus  is  located  just  below  the  rudi- 
mentary sacral  spinous  processes  and  above  the 
coccyx. 

Having  infiltrated  the  skin  and  deeper  soft  tissues 
over  the  hiatus  with  the  anesthetizing  solution,  a  long 
needle  fitted  W'ith  a  wire  stilet  is  thrust  through  the 
membrane  covering  the  hiatus. 

In  penetrating  the  membrane  the  needle  is  inserted 
at  an  angle  of  45  degrees  to  the  skin  surface,  after 
wdiich  its  head  is  depressed  almost  to  a  level  with  the 
body  plane,  and  its  point  diverted  upward  exactly  in 
the  midline  following  the  axis  of  the  canal  for  a  dis- 
tance of  13^  to  2  inches  (Lewis  and  Bartels). 

When  the  needle  is  in  situ,  the  stilet  is  withdrawn. 
If   cerebrospinal   fluid   appears,   the   needle  must  be 


20 


GYNECOPLASTIC   TECHNOLOGY. 


withdrawn  until  the  flow  ceases,  when  its  point  will 
be  in  the  sacral  canal. 

If  blood  escapes  through  the  needle,  a  vein  has 
been  entered,  and  the  position  of  the  needle  must  be 
changed  to  avoid  an  intravenous  injection  of  the  anes- 
thetic. It  is  not  necessary  to  introduce  the  needle  be- 
yond 3  or  4  cm. 


Fig.  2. — I.  Showing-  first  coccygeal  vertebra  fused  with  sacrum. 
Upper  end  of  hiatus  low  down  between  the  fourth  and  fifth  sacral 
foramina.  Hiatus  well  formed.  Margins  of  hiatus  formed  by  the 
fused  spinous  processes  of  the  fifth  sacral  and  first  coccygeal 
vertebrae.  The  fifth  foramen  complete  posteriorly  and  anteriorly. 
H.  Fusion  of  first  coccygeal  vertebra  with  sacrum.  The  fifth  fora- 
men complete  in  front;  represented  by  a  fissure  behind.  Hiatus 
represented  by  a  transverse  slit  at  the  level  of  the  fifth  sacral 
foramen.     (/.  E.  Thompson.) 


If  the  needle  is  in  the  sacral  canal,  there  is  prac- 
tically no  obstruction  to  the  flow  of  fluid  from  the 
syringe.  If  it  should  lie  superficial  to  the  sacrum, 
there  will  be  considerable  resistance,  and  a  subcutan- 
eous bulging  develops  over  the  site  of  the  injection. 


SACRAL  ANESTHESIA. 


21 


Laewen  determined  that  less  than  20  mils  of  a  i^^ 
to  2  per  cent,  novocain  solution  will  prove  inefifectual. 

Anesthesia  is  first  noted  at  the  tip  of  the  coccyx, 
from  which  it  gradually  extends  over  the  perineum, 
then  laterally  to  the  gluteal  region. 

The  clitoris  is  the  last  to  become  anesthetized. 
In  other  words,  the  coccygeal  plexus  is  first  to  become 


Fig.  3. — I.  Hiatus  very  long,  and  shaped  like  a  horse-shoe.  The 
upper  end  is  at  the  level  of  the  third  sacral  foramen.  The  mar- 
gins of  the  hiatus  are  formed  by  two  flattened  ridges,  in  which 
can  be  seen  rudiments  of  the  spinous  processes  of  the  fourth  and 
fifth  sacral  vertebrae.  H.  Hiatus  very  long,  and  shaped  like  an 
isosceles  triangle.  The  upper  end  reaches  to  the  upper  margin  of 
the  third  sacral  foramen.  The  margins  are  flattened,  and  are 
formed  by  the  fused  spinous  processes  of  the  fourth  and  fifth  sac- 
ral vertebrte.     (/.  E.  Thompson.) 

anesthetized,  followed  by  the  hemorrhoidal,  the  per- 
ineal, and,  lastly,  the  pudendal  plexus. 

It  is  diiBcult  to  determine  the  extent  of  the  anes- 
thesia, as  the  various  operations  involve  more  or  less 
traction  upon  tissues  innervated  by  nerves  originating 
above  the  caudal  region. 


22 


GYNECOPLASTIC   TECHNOLOGY. 


Thompson  states:  "As  a  rule,  one  injection  of  3 
tablets,  each  of  which  contains  novocain,  0.125  Gm., 
suprarenin,  0.000125  Gm.,  dissolved  in  30  mils  of  dis- 
tilled water,  to  which  10  drops  of  a  50  per  cent,  solu- 
tion of  calcium  chloride  is  added,  is  sufficient,  and  at 
the  end  of  half  an  hour  anesthesia  is  complete  in  the 
branches  supplied  by  the  sacral  nerves. 


Coccyx^' 


Fig.  4. — I.  Curved  type  of  sacrum,  fused  coccyx;  opening  of 
hiatus  shown  by  a  cross.  II.  Long  flattened  type  of  sacrum,  fused 
coccyx;  opening  of  hiatus  shown  by  a  cross.  III.  Short  flattened 
type  of  sacrum;,  opening  of  hiatus  shown  by  a  cross.  IV. 
Curved  type  of  sacrum;  opening  of  hiatus  shown  by  a  cross. 
(/.  E,  Thompson.') 


"We  have  injected  a  second  time  not  infrequently, 
and  have  never  failed  after  a  second  injection  to  se- 
cure perfect  anesthesia.  The  quantity  of  novocain 
used  has  been  considerable,  as  much  as  0.750  Gm. 
having  been  introduced  into  the  peridural  space  in 


SACRAL  ANESTHESIA. 


23 


two  injections.     As  far  as  our  experience  goes,  we 
have  never  seen  evidence  of  toxic  symptoms." 

The  appended  chart,  designed  by  Prof.  WilHam 
Keiller  for  Thompson's  article  quoted  above,  depicts 
the  areas  of  anesthesia,  the  time  taken  for  the  anes- 
thetic to  produce  its  effect,  and  the  spinal  segments 
involved  by  diffusion. 


L.I 


u 


GLANS Complete,  30  min. 

.■57X3.4 


..-./.y.  /--yc. Partial,  15  mm. 


.  Partial,  12  min.;  complete,  15 
min. 


Complete,  la  min. 

— Female.    Perineal  view. 

Fig.  5. — "Sacral  blocking."    Areas  of  anesthesia,  time  of  manifes- 
tation, and  spinal  segments  involved  by  diffusion. 

To  Cathelin  belongs  the  credit  for  first  demon- 
strating the  feasibility  of  producing  local  anesthesia 
by  extradm-al  injection  through  the  hiatus  sacralis 
into  the  sacral  canal.  He  used  cocain,  but  was  unable 
to  produce  satisfactory  results  in  the  human  subject 
with  safe  cjuantities  of  this  drug. 

Stockel  utilized  Cathelin's  method  successfully  in 
parturient  women,  substituting  30  mils  of  a  3^  per 
cent,  solution  of  novocain  for  cocain. 

Schlimpert  and  Schneider  report  34  operations, 
comprising  perineal  repairs,  curettage,  rectoscopy  and 
C3^stoscopy,  under  sacral  novocain  anesthesia. 


24  GYNECOPLASTIC   TECHNOLOGY. 

Laewen  gives  a  detailed  report  of  80  cases,  with  7 
failures,  and  recommends  the  method  for  forceps  de- 
livery and  repair  of  obstetric  injuries. 

Schlimpert,  in  a  second  communication,  enumer- 
ates 55  cases,  with  11  failures.  In  12  others,  general 
anesthesia  had  to  be  induced,  owing  to  the  long  dura- 
tion of  the  operation. 

Hertzler  contends:  "My  own  experience  with 
'sacral  blocking'  has  convinced  me  of  the  value  of  the 
method  in  perineal  operations.  It  sometimes  fails 
more  or  less,  but  if  one  is  ready  to  supplement  the  sac- 
ral blocking  by  local  infiltration,  the  shortcomings  of 
the  method  do  not  work  much  of  a  hardship. 

"My  plan  is  to  use  quinine  in  the  sacral  canal,  and 
novocain-epinephrin  for  local  infiltration,  or  vice 
versa. 

"In  this  manner  it  is  possible  to  meet  all  indica- 
tions without  using  an  excess  of  the  novocain-epi- 
nephrin solution. 

"By  using  this  combined  method,  I  have  never  had 
to  resort  to  general  anesthesia. 

"The  usual  cause  of  failure,  aside  from  such  gross 
errors  as  injecting  the  fluid  outside  the  canal  or  into  a 
vessel,  results  from  the  use  of  too  small  an  amount  of 
solution. 

"Two  ounces  of  a  ^  per  cent,  solution  give  more 
certain  results  than  half  this  amount  of  twice  the 
strength. 

"The  large  nerve  trunks  of  the  legs  may  become 
anesthetized.  This  may  result  in  complete  sensory 
anesthesia,  and  may  alTect  the  motor  fibres  to  the 
extent  that  the  patient  is  unable  to  walk  for  several 
hours.    This  soon  passes  off." 


SACRAL  ANESTHESIA.  25 

In  operations  on  the  cervix,  the  traction  pain  is 
very  marked,  owing  to  the  pull  on  the  broad  ligaments. 

The  same  holds  good  for  the  manipulation  neces- 
sary in  levator  myorrhaphy  for  perineal  lacerations, 
necessitating  the  local  infiltration  of  the  levator  ani 
bundles  prior  to  their  mobilization  and  suture. 

When  all  is  said  and  done,  it  must  be  stated  that  at 
the  present  writing,  notwithstanding  the  positive 
claims  embodied  in  the  quoted  excerpts,  the  region  of 
the  female  genitalia  and  the  pelvic  floor  do  not  offer 
an  ideal  field  for  major  surgery  under  sacral  anes- 
thesia. The  diversity  in  the  source,  ramification,  and 
anastomosis  of  the  sensory  innervation,  added  to  the 
patient's  attitudinal  discomfort  from  a  necessarily 
prolonged  lithotomy  position,  constitute  intrinsic  ob- 
stacles and  disconcerting  factors,  which  to  a  greater 
or  lesser  degree  are  encountered  in  a  large  majority 
of  cases. 


CHAPTER  IV. 

Tracheloplasty. 

Laceration  of  the  cervix  uteri  was  recognized  in 
ancient  times. 

The  textbooks  on  Obstetrics  pubhshed  during  the 
eighteenth  century  refer  to  the  "cleft  condition  of  the 
cervix"  as  a  product  of  difficult  delivery,  and  to  the 
cicatricial  tissue  resulting  from  previous  lacerations 
as  a  cause  of  tedious  labor. 

J.  H,  Bennett  wrote  extensively  on  the  appear- 
ance and  results,  of  the  lesion  under  the  title,  "Ulcer- 
ation of  the  Cervix."  This  pathological  misnomer 
established  the  general  practice  of  treatment  by  caus- 
tics, in  the  attempt  to  heal  the  supposed  ulcer. 

Microscopic  examination  of  such  an  "ulceration," 
when  removed  intact  from  the  living  during  opera- 
tion, will  invariably  disclose  that  the  apparent  ulcer 
is  covered  by  a  layer  of  normal  epithelium,  that  its 
granular  appearance  is  produced  by  surface  corru- 
gations, and  that  its  tendency  to  bleed  on  touch  is  due 
to  the  extreme  friability  of  its  thin  epithelial  covering. 

Modern  textbooks  generally  apply  the  term  "ero- 
sion" to  these  readily  bleeding  patches,  and  describe 
two  types : 

(i)  The  "papillary  erosion",  in  which  the  affec- 
ted surface  presents  a  field  studded  with  papillae,  each 
covered  with  a  single  layer  of  columnar  epithelium; 
and 

(26) 


TRACHELOPLASTY.  27 

(2)  "Glandular  erosion",  a  condition  where  the 
surface  is  smoother,  but  in  which  many  cervical 
glands  are  present.  This  latter  form  is  also  desig- 
nated as  "eversion". 

The  term  "erosion",  however,  like  "ulceration"', 
is  inapplicable,  as  it  suggests  a  solution  of  surface 
continuity,  while  all  of  these  involved  areas  actually 
present  an  intact  epithelial  covering.  The  whole  pro- 
cess simply  represents  an  extension  of  the  diseased 
endocervical  mucosa  (chronic  endocervicitis)  to  the 
vaginal  covering  of  the  cervix.  In  this  situation  the 
tissue  is  subjected  to  friction  and  to  the  irritation  of 
the  acid  vaginal  secretions. 

As  the  disease  progresses,  the  squamous  vaginal 
epithelium  proliferates  over  the  attected  surface, 
gradually  replacing  the  columnar  endocervical  epi- 
thelium, and  thus  occludes  the  outlets  of  all  subjacent 
cervical  glands  within  the  involved  area. 

The  resulting  retention  cysts  finally  penetrate 
from  the  inner  to  the  vaginal  aspect  of  the  cervix  as 
small  shot-like  elevations,  familiarly  known  as  "na- 
bothian  follicles",  the  presence  of  which  is  invariably 
pathognomonic  of  chronic  endocervicitis. 

Ambrose  Pare  first  advocated  amputation  of  the 
cervix. 

Osiander  in  1802  published  the  first  detailed  treat- 
ise on  the  operative  procedure,  after  performing  it 
upon  2T,  patients. 

Among  the  advocates  of  the  method  as  proposed 
by  Osiander  appear  the  names  of  Dupuytren.  Recam- 
ier,  Lisfranc,  and  others  of  equal  fame. 

The  operation  was  performed  by  means  of  the 
bistoury,  scissors,  the  ecraseur  and  galvano-cautery ; 


28  GYNECOPLASTIC   TECHNOLOGY. 

the  latter  method  was  perfected  by  John  Byrne,  of 
Brooklyn.  All  of  these  methods  left  an  uncovered 
raw  cervical  stump  to  heal  by  granulation. 

The  first  plastic  amputation  of  the  cervix  uteri, 
utilizing"  a  cuff  of  vaginal  mucosa  as  a  stump  cover- 
ing, was  practiced  by  Marion  Sims  in  1861.  One 
year  later  T.  A.  Emmet  performed  his  first  success- 
ful trachelorrhaphy,  the  technique  and  results  of 
which,  however,  were  not  published  until  1874.  In 
discussing  Emmet's  operation,  Sims  declared:  "We 
can't  modify  it,  we  can't  change  it,  for  it  is  perfect 
— perfect  in  its  method  and  perfect  in  its  results." 

Emanating  from  so  prominent  a  source,  and  en- 
dorsed by  such  authority,  these  operations,  which 
embody  the  origin  and  principles  of  all  subsequent 
tracheloplastic  methods,  found  enthusiastic  adoption 
in  America,  and  to  a  large  extent  in  England,  while 
at  the  same  time  their  introduction  among  Conti- 
nental surgeons  instigated  an  interminable  maze  of 
controversy  and  modifications. 

Today,  after  a  tenure  of  nearly  half  a  century, 
the  conviction  is  gaining  ground  that  the  reputed 
efficacy  of  these  standardized  operations  is  not  sub- 
stantiated by  final  analysis. 

This  is  convincingly  revealed  in  a  recent  report 
by  Leonard,  from  Howard  Kelly's  clinic  at  the  Johns 
Hopkins  Hospital,  who  tabulated  the  immediate  and 
end  results  of  the  classic  cervix  amputations  per- 
formed during  the  past  twenty  years. 

One  hundred  and  twenty-eight  complete  postoper- 
ative histories,  from  among  400  cases,  forced  Leonard 
to  conclusions,  which  "were  quite  unexpected,  and  in 
many  ways  disappointing." 


TRACHELOPLASTY.  29 

"Nearly  5  per  cent,  of  the  patients  presented  seri- 
ous postoperative  hemorrhage,  occasionally  after  es- 
tablished convalescence. 

"Ten  per  cent,  of  the  cases  suffered  from  decided 
augmentation  of  a  preexisting  menorrhagia  or  dys- 
menorrhea. 

"Four-fifths  of  the  women,  in  whom  pregnancy 
might  reasonably  have  been  anticipated  to  follow  the 
operation,  remained  sterile. 

"On  the  other  hand,  50  per  cent,  of  the  pregnan- 
cies occurring  after  cervix  amputation  terminated 
prematurely,  while  among  the  few  who  progressed 
to  full  term  even  a  larger  proportion  experienced 
difficult  and  prolonged  labor. 

"The  operation  in  all  of  the  cases  presented  con- 
sisted of  the  classic  circular  amputation,  removing 
about  three  centimeters  of  the  cervix  above  the  ex- 
ternal OS." 

Actuated  by  these  "disappointing  results",  Leonard 
next  tabulated  the  postoperative  effects  of  trachelor- 
rhaphy for  comparative  analysis  with  those  of  cervix' 
amputation^  concluding  as  follows: 

"The  presence  of  a  marked  endocervicitis  should 
be  considered  as  contraindicating  simple  trachelor- 
rhaphy, for  although  trachelorrhaphy  may  render  a 
mild  endocervicitis  more  amenable  to  treatment,  it 
cannot  be  considered,  like  amputation  of  the  cervix,  a 
curative  measure  for  this  condition. 

"Fertility  is  much  more  likely  to  follow  trachelor- 
rhaphy than  amputation  of  the  cervix. 

"After  amputation  of  the  cervix,  the  incidence  of 
abortion  and  premature  delivery  is  greatly  increased. 


30  GYNECOPLASTIC   TECHNOLOGY. 

while  trachelorrhaphy  has  no  effect  upon  the  course 
of  subsequent  pregnancy. 

"Labor  after  cervix  amputation  is  usually  difficult, 
while  after  trachelorrhaphy  it  is  almost  always  nor- 
mal; hence  amputation  of  the  cervix  is  to  be  avoided 
in  the  child-bearing  period,  trachelorrhaphy  being  the 
operation  of  choice  in  properly  selected  cases." 

Accepting  these  data  from  authoritative  sources, 
as  a  correct  exposition  of  facts,  the  obvious  deduc- 
tion is,  that  with  chronic  endo cervicitis  as  the  recog- 
nized pathologic  indicator,  trachelorrhaphy  is  an  in- 
adequate, and  cervix  amputation  an  injurious,  oper- 
ation. 

That  it  is  not  the  tear  in  the  cervix,  but  the  in- 
duced complications,  which  bring  the  patient  to  the 
operating  table,  is  amply  demonstrated  by  the  count- 
less women  who  bear  cleft  cervices,  presenting  un- 
united cicatrized  edges,  that  are  unproductive  of  any 
symptoms  whatsoever,  and  it  follows  that  the  limita- 
tions of  trachelorrhaphy,  like  the  indications  for  cer- 
vix amputation,  must  be  governed  by  the  nature  and 
degree  of  existing  concomitants  and  not  by  the  ex- 
tent of  the  cervical  injury.  A  single  shallow  tear  may 
initiate  the  most  serious  train  of  complications  in  one 
patient,  while  a  more  extensive  multiple  injury  may 
prove  perfectly  innocuous  in  another;  and  the  ques- 
tion naturally  obtrudes  itself:  What  factor  estab- 
lishes the  immunity  from  symptoms  in  the  one  and 
the  morbidity  of  the  other?  Why  is  trachelorrhaphy 
ineffectual,  and  cervix  amputation  harmful,  in  so 
large  a  proportion  of  the  cases  ? 

The  solution  to  these  problems  demands  a  radical 
revision  of  current  elementary  conceptions  of  cervical 


TRACHELOPLASTY.  31 

disease,  and  modification  in  llic  technique  of  its  oper- 
ative cure. 

The  fundamental  dominant  that  estabhshes  the 
morbidity  of  any  cervical  lesion  is  the  incidence  of 
infection. 

Clinically,  the  course  of  such  infection  assumes 
one  of  two  types:  it  may  reveal  its  initial  stage  as  a 
frank  puerperal  sepsis  of  varying  intensity,  with  a 
gradual  subsidence  of  its  systemic  manifestations ;  or, 
what  is  more  common,  it  pursues  a  more  or  less  in- 
sidious course  from  the  beginning.  The  first  type 
usually  merges  into  the  second,  so  that  ultimately 
both  types  eventuate  in  varying  degrees  of  the  same 
symptom-complex,  designated  as  "chronic  endocervi- 
citis". 


CHAPTER  V. 

Chronic  Endocervicitis. 

Chronic  endocervicitis  or  endotrachelitis  is  the 
most  prevalent  and  most  familiar  objective  manifes- 
tation among  gynecological  disorders.  It  constitutes 
a  concrete  clinical  entity  of  pathogenic  potentialities 
which  may  menace  the  integrity  of  the  entire  gynecic 
system.  Nevertheless,  it  is  accorded  no  special  con- 
sideration as  such  in  current  textbooks,  where  its  de- 
scription is  scattered  among  numerous  chapters  as  an 
incidental  feature  under  various  captions,  as  "cerv- 
ical catarrh,"  "simple  follicular  or  papillary  erosion," 
"eversion,"  "ectropium,"  "ulceration,"  "hypertrophy 
of  the  cervix,"  etc.,  all  of  which  depict  only  different 
features  of  the  same  infectious  process,  the  nature, 
course,  and  significance  of  which  is  obscured  by  per- 
petuated misconceptions  and  misleading  dogma  that 
dominate  its  ineffectual  treatment. 

In  structure  and  in  function,  a  sharp  line  of  de- 
marcation differentiates  the  cervical  mucosa  from  the 
corporeal  endometrium.  Physiologically,  the  cervical 
canal  presents  nothing  more  than  a  passive  communi- 
cating channel  between  the  vagina  and  the  uterine 
cavity  proper.  The  cervical  mucosa  is  composed  of 
deeply  penetrating  racemose  glands,  which  simply 
secrete  mucus.  It  does  not  participate  in  the  cyclic 
metamorphosis  of  the  corporeal  endometrium  essen- 
tial to  menstruation  or  deciduation.  But  more  sig- 
nificant than  this  structural  and  functional  con- 
(32) 


PLATE  I. 


Chronic  eiulocervicitis.  "Follicular  erosion."  Showing  sharp 
line  of  demarcation  between  the  diseased  cervical  lining  and  the 
normal    corporeal    endometrium.      {Palmer   Fiiidlcy.) 


CHRONIC   EXDOCERVICITIS. 


33 


trast  is  the  striking"  disparity  in  pathological  mani- 
festations displayed  below  and  above  the  internal  os. 
The  cervical  mucosa  evinces  a  marked  suscepti- 
bility to  infection,  while  the  corporeal  endometrium, 
contrary  to  orthodox   conception,   is   practically   im- 


Fig.  6. — Normal  cervical  glands.     Note  racemose  outlines 
and  depth  of  penetration. 


mune.     In  short,  the  cervical  mucosa  could  be  aptly 
termed  the  tonsil  of  the  uterus. 

Kundradt  first,  in  1873,  ^^'^^  more  recently  Hitsch- 
man  and  Adler,  have  conclusively  demonstrated  that 
all  of  the  histologic  features  generally  depicted  as 


34 


GYNECOPLASTIC   TECHNOLOGY. 


"chronic  endometritis",  inclusive  of  typical  round-cell 
infiltration,  constitute  only  the  normal  transition  of 
the  endometrium  into  the  transudative  phase  of  its 
menstrual  cycle.  Even  that  infrequent  condition  clin- 
ically labelled  "hypertrophic  endometritis",  more 
correctly  termed  glandular  hyperplasia,  is  never  in- 
flammatory in  character,  but  a  functional  adenoma- 


Fig.   7. — Normal   endocervical  mucosa,     a.   Gland   opening  cut 

obliquely    in    sectioning,      b,    Columnar    epithelium     (ciliated),  c, 

Connective    tissue    stroma,      d.    Capillaries    filled    with    blood,  e, 
Oblique  section  through  cervical  glands. 


tons  overgrowth,  analogous  to  that  presented  by  the 
thyroid  gland  in  Graves'  disease.  While  this  subject 
is  still  a  matter  of  academic  controversy,  the  majority 
of  pathologists  concede  that,  clinically  at  least,  chronic 
corporeal  endometritis  may  be  safely  discarded. 

The  most  recent  bacteriological  studies  fully  sub- 
stantiate the  relative  immunity  of  the  corporeal  endo- 


CHROXIC    ENDOCERVICITIS.  35 

nietriuiii  to  ascending"  surface  infection  from  the 
cervical  mucosa. 

Arthur  H.  Curtis,  in  "A  Combined  Bacteriological 
and  Histological  Study  of  the  Endometrium  in  Health 
and  Disease",  embracing  a  series  of  ii8  cases,  states: 

"It  has  1:een  my  object  to  make  a  study  of  the  en- 
dometrium, exclusive  of  the  cervix,  in  all  conditions 
usually  encountered  except  those  associated  with 
pregnancy.  All  material  has  been  secured  from  uteri 
removed  at  operation.  Scrapings  from  the  endome- 
trium are  so  liable  to  contamination  that  cultures 
from  them  are  not  included  in  this  series. 

"The  variety  of  media  employed  and  other  pro- 
cediu'es  followed  are  in  close  accord  with  details  de- 
scribed in  the  bacteriological  study  of  uterine  fibroids 
{I.e.). 

"\A'ith  sterile  instruments  and  culture  material  in 
readiness,  the  stump  of  the  cervix  and  entire  length 
of  the  peritoneal  surface  of  the  uterus  are  cauterized, 
and  the  anterior  wall  bisected.  The  greater  part  of 
the  endometrium  is  excised  in  its  entire  thickness, 
down  to  the  muscle  layer,  and  is  placed  in  sterile  con- 
tainers to  be  ground  and  cultured.  The  remainder 
serves  for  immediate  examination,  for  inoculation  of 
culture  media  with  imground  tissue,  and  for  micro- 
scopic study. 

"This  technique  affords  immeasurably  more  ma- 
terial than  is  secured  by  pipette  or  platinum  loop. 
Through  examination  of  so  much  endometrium,  in- 
cluding the  deeper  portion,  it  is  hoped  that  the  possi- 
bility of  overlooking  dormant  infections  has  been  re- 
duced to  a  minimum. 

"From  this  work  I  believe  that  the  endometrium 


26 


GYNECOPLASTIC   TECHNOLOGY. 


of  nullipara,  without  history  or  gross  evidence  of 
pelvic  infection,  is  almost  invariably  free  from  bac- 
teria; it  is  also  microscopically  normal. 


Fig.  8. — Normal  cervical  gland.  High-power  view  showing 
racemose  form,  lined  with  a  single  layer  of  tall  columnar  epi- 
thelium, each  cell  with  its  nucleus  at  the  base  set  upon  a  base- 
ment membrane.  These  terminal  tufts  extend  deeply  into  the 
cervical  tissues,  and,  once  infected,  nothing  short  of  extirpation  will 
prove  curative. 

"Almost  all  women  who  have  undergone  normal 
presrnancy,  with  pelvic  history  otherwise  negative, 
like\A'ise  possess  bacteria-free  endometria.  The  pos- 
sibility of   infection   appears   to   be  but  slightly  in- 


CHROXIC    EXDOCERVICITJS. 


37 


creased  1)y  |)rei;'nancy  and  the  usual  changes  conse- 
quent thereto. 

"Patients  with  a  liistory  of  chronic  infection,  from 
whose  endometrium  hacteria  are  ohtainahle,  ahnost  all 
have  salpingitis  with  ecjually  good  growth.  Pyoiiicfra 
and  recent  e.vploratiou  of  the  uterus  excepted,  the  eii- 
doijietriuiii  almost  never  shows  bacteria  except  zvhen 
there  is  infection  of  adjacent  pelvic  tissues.     Chronic 


Fig.  9. — Xormal   utricular  glands  of  the  corporeal   endo- 
metrium, showing  their  straight  tubular  form. 

endometritis,  per  se,  zvitJi  bacteria  f'rescnt  in  smears 
or  cultures,  is  practically  to  be  ruled  out  as  a  clinical 
entity. 

"In  certain  cases  normal  scrapings  have  been  ob- 
tained from  the  uterus;  then,  several  days  thereafter, 
in  the  endometrium  secured  by  hysterectomy,  mixed 
cultures  and  endometritis  have  been  found.  Infection 
is  perhaps  not  a  customary  result  of  curettage,  but  it 
appears  not  uncommon. 

"Some  will  wonder  why,  if  curettage  tends  to  con- 


38 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  10. — Corporeal  endometrium  in  the  transudative  phase 
("premenstrual")  of  its  menstrual  cycle,  showing  the  normal  pre- 
sence of  round  cells  and  polymorphonuclear  infiltration,  simulating 
an  inflammatory  process. 


CHRONIC   EXDOCERVICITIS. 


39 


taminate  the  endometrium,  infection  does  not  compli- 
cate hysterectomy  in  patients  with  prehminary  curet- 
tage. Fortunately,  nature  can  dispose  of  a  few 
bacteria  at  the  time  they  are  introduced.  But  patients 
not  operated  upon  until  several  days  later,  when  the 
bacteria  have  had  time  to  multiply,  I  believe  are  not 
ideal  subjects.  The  problem  is,  in  miniature,  that 
which  confronts  the  abortionist — he  can  meddle  once 
with  comparative  safety,  Imt  if  tempted  to  interfere 


Fig.  11. — Automatic  contractions  of  a  non-pregnant  uterus 
four,  hours  after  hysterectomy.  At  E,  Epinephrin  1 :  2,000,000. 
(Lieb.) 


again,  to  complete  the  task,  he  works  in  a  contami- 
nated and  dangerous  field." 

Nevertheless,  the  cardinal  symptoms  of  chronic 
endocervicitis — namely,  the  disturbances  in  menstru- 
ation and  deciduation — point  so  directly  to  an  in- 
volvement of  the  corporeal  endometrium,  that  their 
occurrence  in  the  absence  of  endometritis  demands 
elucidation. 

To  correlate  the  pathology  and  symptomatology  of 


40 


GYNECOPLASTIC   TECHNOLOGY. 


chronic  endocervicitis  and  place  its  therapeutics  on  a 
rational  basis,  we  must  revise  some  current  concep- 
tions of  the  myometrial  structure  and  its  dynamics. 

The  specific  functions  of  the  uterus  in  menstrua- 
tion and  gestation  demand  a  wide  range  in  the  control 
of  its  blood  supply,  and,  like  the  heart,  the  uterus 
automatically  responds  to  its  fluctuating  circulatory 
necessities  by  rhythmic  contraction  and  dilatation,  not 
only  during  pregnancy,  but  throughout  its  functional 


Fig.  12. — Automatic  contractions  of  a  muscle  strip  from  a  non- 
pregnant uterus  three  hours  after  hysterectomy.  At  C,  Pituitrin 
I:    100.     {Lieb.) 


existence  (Henricius).  An  immobile  muscle,  whether 
in  the  uterus  or  elsewhere,  degenerates.  Moreover, 
the  uterine  veins,  being  devoid  of  valves,  leave  no  pro- 
vision other  than  muscular  contractions  to  prevent 
local  circulatory  stasis  and  its  consequences. 

The  myometrium  is  composed  of  smooth  muscle 
fibres,  which,  like  all  non-striated  muscle,  exhibits  the 
intrinsic  phenomenon  of  rhythmic  automatic  contrac- 
tion independent  of  any  neurogenic  stimuli. 


CHRONIC    EXDOCERVICITIS.  41 

Two  familiar  clinical  manifestations  will  serve  as 
a  practical  demonstration  to  depict  the  extreme  phases 
of  this  muscular  virility  in  the  non-gravid  uterus. 
The  time-honored  practice  of  applying  silver  nitrate 
solutions  on  a  cotton-wrapped  probe  to  the  endome- 
trium induces,  in  some  patients,  a  most  distressing 
tetanic  response  of  the  whole  uterine  musculature, 
which  firmly  clutches  the  probe,  causes  violent  colicky 
pains,  and  mild  but  unmistakable  symptoms  of  general 
shock.  Xo  hibernating  muscle  can  manifest  such  to- 
nicity. On  the  other  hand,  an  equally  distracting 
moment  is  experienced  when,  during  a  curettage,  the 
operator  suddenly  finds  himself  "beyond  his  depth,"' 
the  curette  losing  contact  by  a  paralytic  dilatation  of 
the  uterine  cavity,  simulating  traumatic  perforation  of 
the  uterine  wall.  Only  a  virile  muscle  exhibits  such 
absolute  paralytic  flaccidity.  Between  these  two  ex- 
tremes we  will  find  CAxry  grade  of  perverted  mus- 
cular irritability,  with  its  objective  and  subjective 
concomitants. 

The  key  to  the  architectural  scheme  of  the  uterine 
musculature  is  revealed  in  its  formative,  not  in  its 
matured  state,  and  to  gain  a  clear  conception  of  its 
mechanism  it  is  necessary  to  discard  the  accepted  sub- 
division of  this  single  muscle  into  scA'cral  layers. 
Such  a  subdivision  is  pitrely  arbitrary.  There  are  no 
distinct  layers,  but  a  single  muscle,  presenting  dift'er- 
ent  angles  in  the  course  of  its  component  bundles. 
Briefly  stated,  these  bundles  are  arranged  in  a  suc- 
cession of  fan-shaped  muscle-sprays  that  wind  spir- 
ally downward  from  each  fallopian  angle  throughout 
the  whole  uterus  to  the  external  os. 

Every  muscle  contracts  toward  its  fixed  point,  and 


42 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  13. — Sagittal  section  of  the  uterus,  a,  Vaginal  mucosa. 
b.  Squamous  epithelium,  c.  Connective  tissue  stroma,  d,  External 
OS.  e.  Internal  os.  /,  Cervical  mucosa,  g,  Endometrium,  h-h, 
Musculature  of  cervix  and  corpus  uteri,    i,  Peritoneal  coat.  (Abel.) 


CHRONIC    ENDOCERVICITIS.  43 

for  the  uterine  muscle  such  relative  fixed  ])oints  are 
furnished  through  its  fascicular  prolongations  in  the 
round  and  broad  ligaments  at  the  pelvic  brim. 

The  rhythmical  contractions  of  the  myometrium 
are  necessary,  not  only  in  maintaining  the  nutritional 
and  functional  integrity  of  the  uterus  as  a  whole,  but 
they  serve  the  equally  essential  purpose  of  drainage. 
The  cervical  secretion  must  find  free  egress  from  the 
normal,  and  more  especially  from  the  diseased,  con- 
ditions of  its  mucosa. 

In  the  normal  state,  such  drainage  is  effected,  not 
merely  by  a  passive  outflow  through  a  patent  os,  but 
by  the  active  rhythmic  expression  resulting  from 
uterine  contractions. 

To  comprehend  this  mechanism,  it  is  necessary  to 
dispel  the  anatomical  myth  of  a  cervical  sphinctre. 
Such  a  sphinctre  would  imply  the  existence  of  a  con- 
centrically contracting  muscular  ring.  The  structural 
design  of  the  cervical  musculature  precludes  any  con- 
centric closure  of  its  outlet,  which  dilates  with  every 
uterine  contraction,  because  its  fibres,  continuous  with 
those  of  the  corpus  uteri,  do  not  at  any  point  com- 
pletely encircle  the  cervix,  but  are  disposed  in  serried 
successions  of  oblique  circle  segments,  which  by  con- 
tracting spirally  upwards  necessarily  shorten  every 
diameter  of  the  uterine  cavity,  and,  by  uncoiling  in 
the  cervix,  widen  the  os  like  an  iris  diaphragm  in  a 
microscope. 

Cervical  dilatation  thus  becomes  an  integral  part 
of  uterine  contractions  instead  of  a  passive  relaxation 
in  a  hypothetical  sphinctre.  Incidentally,  this  mechan- 
ism explains  the  apparent  obliteration  of  the  cervix  in 
labor. 


44  GYNECOPLASTIC   TECHNOLOGY. 

As  already  emphasized,  it  is  not  the  laceration  as 
such,  but  the  incidence  of  its  infection  that  determines 
the  morbidity  of  a  cervical  lesion.  In  the  cervix,  as 
elsewhere,  every  infection  incites  the  greatest  reaction 
in  its  lymphatic  system.  The  enormous  resorptive 
capacity  of  the  uterus  is  displayed  in  its  gravid  and 
puerperal  state. 

It  is  nearly  fifty  years  since  Leopold  clearly  demon- 
strated the  normal  uterine  lymphatic  circulation. 
Nevertheless,  barring  its  disseminating  role  in  malig- 
nancy, the  domination  of  this  element  in  the  general 
pathology  of  gynecological  infections  has  been  prac- 
tically ignored. 

Quoting  briefly  from  Leopold's  description,  which 
stands  unchallenged  to  this  day,  the  uterine  lymph 
current  may  be  traced  from  its  lacunar  origin  in  the 
cervical  and  corporeal  mucosa,  through  minute  fun- 
nel-shaped ostia,  directly  to  the  myometrium.  Here  it 
branches  into  an  extensive  capillary  net,  which, 
spreading  on  the  perimysium,  penetrates  and  en- 
meshes every  bundle  and  fascicle  of  the  entire  uterine 
musculature  to  its  subperitoneal  surface,  whence  it 
drains  into  two  main  collecting  channels  that  course 
parallel  to  the  uterine  and  ovarian  blood-vessels  at  the 
base  and  top  of  the  broad  ligament. 

It  is  this  normal  lymphatic  envelopment  of  the 
perimysial  sheaths  and  adnexa  that  determines  the 
course  of  an  infection  from  the  cervical  mucosa — not 
via  the  uterine  cavity  and  tubal  lumina,  but  along  the 
intramuscular  planes  of  the  uterine  and  tubal  zvalls 
to  the  ovarian  tunica  albuginea,  as  an  ascending  lym- 
phangitis whose  pathological  trail  impairs  normal 
uterine   contractions   by   infiltrating   the   myometrial 


PLATE  IT. 


'f 


Injection  specimen,  normal  nuUiparous  uterus,  transverse 
section  of  myometrium.  A,  Lj-mphatics  running  on  the  intra- 
muscular septa,  and  enveloping  the  muscle-bundles.  B,  Blood- 
vessels.   C,  Muscle-bundle.     (Lcof'old.) 


Transverse    section    of    uterine    muscle.      A,    Muscle-bundles. 
B,  Intramuscular  septa  carrying  blood-  and  lymph-  vessels. 


CIIROXIC    ENDOCERVICJTIS. 


niiisclc  sheaths,  occasiDnally  cstaljlishing  disseminated 
niihary  myometrial  abscesses;  then  prog'ressing  to  the 
periadnexal  lymphatic  ramifications,  inhi1)its  tubal 
peristalsis,   kinks    the    tubes    and    aq-.f^-lutinates    their 


I  n*^  L-1^ 


0 


Fig_  14. — Periadnexal  lymphatics.  Sheep's  uterus.  H,  Left  horn. 
T,  Tube.  O,  Ovary.  B,  Broad  ligament,  a,  Subserous  lymphatics. 
h,  Collecting  lymph  tube,  c,  Transit  into  broad  ligament  chan- 
nels.    {Leopold.) 

fimbrial  ostia  by  the  production  of  velamentous  bands, 
which  occasionally  create  tubal  diverticuli  with  ectopic 
possibilities;  finally,   reaching  the  ovaries,   the  lym- 


46  GYNECOPLASTIC   TECHNOLOGY. 

phatic  infiltrate  thickens  their  capsular  tunic,  impeding 
the  normal  rupture  and  regression  of  the  graafian 
follicles,  with  ultimate  development  of  retention  cysts. 
In  short,  we  find  a  chronic  ascending  lymphangitis, 
with  its  resultant  impairment  of  uterine,  tubal,  and 
ovarian  function — not  an  endometritis — that  links  the 
pathology  and  symptomatology  of  chronic  endo- 
cervicitis. 

The  pathological  process  as  depicted  naturally 
varies  in  extent  and  degree,  according  to  the  virulence 
of  the  infection  and  the  resistance  of  the  tissues.  It 
may  remain  limited  to  the  racemose  tufts  of  the  cer- 
vical mucosa  indefinitely  in  one  case,  while  in  another 
it  eventuates  in  an  infectious  agglomeration  of  uterus, 
tubes,  and  ovaries. 

Chronic  abscesses  in  and  about  the  broad  liga- 
ments, pyosalpinx,  hydrosalpinx,  sactosalpinx,  tubo- 
ovarian  cysts  and  abscesses,  ovarian  sclerosis,  uterine 
fibrosis — all  of  apparently  insidious  development  and 
obscure  source — will  usually  reveal  their  primary 
focus  in  a  chronically  infected  cervical  mucosa. 

The  surgical  bearing  of  this  is  obvious.  How 
often  is  one  of  the  adnexa  removed  for  periadnexitis, 
and  the  other  at  a  subsequent  operation,  when  both 
could  have  been  saved  by  a  timely  attack  on  the 
original  focus  within  the  cervix?  Parallel  with  the 
pathological  course,  the  intensity  of  its  symptomatic 
manifestations  will  range  from  a  simple  but  persistent 
leucorrhea  to  complete  functional  invalidism. 

Most  important  among  the  derangements  result- 
ing from  chronic  endocervicitis  are  the  disturbances 
in  menstruation,  fecundation,  and  deciduation. 

The  periodic  maturation  and  rupture  of  a  graafian 


CHROXJC    EXDOCERVICITIS. 


47 


follicle,  the  liberation  of  its  contained  ovum,  the  evolu- 
tion and  involution  of  the  corpus  luteum,  and  the  cyclic 
transmutation  of  the  corporeal  endometrium,  consti- 
tute the  cardinal  phases  essential  to  normal  menstrua- 
tion, fecundation,  and  nidation. 


Fig.  IS. — Distribution  and  course  of  the  periuterine 
and  periadnexal  lymphatics. 

It  is  of  clinical  importance  to  note  that  in  the  pre- 
sence of  a  normal  corporeal  endometrium,  menor- 
rhagia,  metrorrhagia,  or  amenorrhea  occurring  in 
the  course  of  chronic  endocervicitis,  must  be  inter- 
preted as  an  abnormal  manifestation  functional  in 
nature,  i.e.,  a  perverted  menstruation  either  aug- 
mented, protracted,  or  inhibited. 


48  GYNECOPLASTIC   TECHNOLOGY. 

Every  menorrhagia  is  obviously  a  periodical  met- 
rorrhagia. The  same  cause  may  be  productive  of  ex- 
cessive menstruation,  of  intermenstrual  hemorrhage, 
or  of  both;  the  "menorrhagia"  frequently  merging 
into  "metrorrhagia,"  making  a  clinical  distinction 
between  them  impossible. 

When  a  bleeding  uterus  presents  a  small  fibroid, 
we  seek  no  further  for  an  explanation  of  the  hemor- 
rhage; and  yet  no  one  has  definitely  explained  why 
one  uterus  harboring  a  fibrous  nodule  bleeds  exces- 
sively, while  another  bearing  enormous  masses  of  a 
similar  nature  does  not  bleed  at  all. 

Still  less  do  we  know  why  there  is  hemorrhage 
from  some  uteri  that  present  no  demonstrable  evi- 
dence of  any  causative  factor  whatsoever ;  and,  lastly, 
we  know  nothing  as  to  the  why  and  how  the  uterus 
bleeds  during  normal  menstruation. 

Coagulation  is  nature's  hemostatic.  The  blood 
shed  from  these  metrorrhagic  uteri,  like  normal  men- 
strual blood,  is  noii-coagiilahle,  and  the  question  nat- 
urally presents  itself:  What  induces  the  normal  in- 
coagulability of  menstrual  blood,  and  what,  if  any,  is 
the  relation  of  this  incoagulability  to  the  abnormal 
bleeding  under  consideration? 

The  hitherto  prevailing  theory  that  attributes  the 
absence  of  clotting  in  menstrual  blood  to  the  presence 
of  viscid  alkaline  mucus  secreted  by  the  cervical  glands 
is  not  tenable,  for  the  blood  shed  from  the  cor- 
poreal endometrium  is  incoagulable  before  it  reaches 
the  cervical  canal.  Moreover,  no  such  admixture  of 
alkaline  mucus  inhibits  coagulation  in  other  coagulable 
fluids  of  the  body. 


PLATE  III. 


Chronic  interstitial  myometritis — "Fibrosis  uteri."  From 
a  patient  34  years  of  age.  Chronic  endocervicitis.  A,  Muscle- 
bundles.  B,  Fibrous  tissue,  section  made  near  the  peritoneal 
surface. 


CHROXIC    EXDOCERVICITIS.  49 

Stripped  of  all  intricate  laboratory  detail,  the 
established  premises  in  the  problem  are  the  following: 

The  general  circulating  blood  during  the  men- 
strual period  and  in  the  hemorrhagic  conditions  here 
considered  shows  normal  coagulative  properties. 

During  menstruation  and  such  uterine  hemor- 
rhages the  corporeal  endometrium  receives  normally 
coagulable  blood  from  the  general  circulation,  and 
sheds  this  blood  in  a  non-coagulable  state. 


Fig.  16. — Thin  periadnexal  adhesions  and  phlebectasia  in  the 
broad  ligament,  from  chronic  myometrial  lymphangitis,  the  result 
of  chronic  endocervicitis. 

Blood  flowing  from  an  experimental  puncture  or 
incision  of  the  uterine  tissues  external  to  the  cervical 
cavity  promptly  clots,  while  the  simultaneous  men- 
strual flow  from  the  interior  of  the  uterus  fails  to 
coagulate. 

The  non-coagulability  of  normal  and  metrorrhagic 
menstrual  blood  discloses  an  identity  in  experimental 
and  clinical  manifestations,  difl:'ering  only  in  degree. 

Under  the  given  conditions,  the  corporeal  endo- 
metrium exercises  a  function  capable  of  rendering 
coagulable  blood  non-coagulable. 


50  GYNECOPLASTIC   TECHNOLOGY. 

This  loss  of  coagulability  in  menstrual  blood  is  not 
due  to  the  absence  of  any  element  essential  to  coagula- 
tion, but  to  the  presence  of  an  inhibiting  substance 
secreted  by  the  corporeal  endometrium,  from  which  it 
may  be  expressed  during  the  menstrual  state. 

The  endometrium  is  apparently  activated  to  the 
secretion  of  this  inhibiting  substance  by  a  hormone 
generated  in  the  ovary. 

The  evidence  of  these  established  phenomena  war- 
rants the  deduction  that  the  biochemic  process  thus 
outlined,  pathologically  augmented,  protracted  or  in- 
hibited, constitutes  an  essential  link  between  chronic 
endocervicitis  and  its  menstrual  aberrations. 

In  the  progressive  cases  of  chronic  endocervicitis, 
the  ascending  myometrial  lymphangitis  (myome- 
tritis) inhibits  uterine  contractions.  The  blood-cur- 
rent in  the  valveless  uterine  veins,  thus  deprived  of  its 
essential  vis  a  tergo,  is  slowed.  The  resultant  circula- 
tory stasis  augments  the  menstrual  flow  in  the  non- 
pregnant ( menorrhagia ) . 

The  thickened  ovarian  tunica  albuginea  (perio- 
ophoritis) may  impede  the  mattiration  and  rupture  of 
a  graafian  follicle,  with  consequent  inhibition  of  men- 
struation (amenorrhea),  or,  retarding  follicular  con- 
traction and  involution,  protract  the  menstrual  flow 
(metrorrhagia). 

The  myometrial  sensory  nerve  filaments  penetrate 
the  muscle  sheaths;  hence  the  normal  uterine  con- 
tractions, intensified  during  menstruation,  compress- 
ing the  infiltrated  perimyseal  areas,  become  painful 
(  dysmenorrhea ) . 

It  is  a  marked  characteristic  of  the  dysmenor- 


CHROXIC    EXDOCEKVICITIS.  51 

rhea  resultini^'  from  endocervicitis  that  it  subsides 
after  the  inaiis^uration  of  a  full  flow. 

Agi^lutination  and  occlusion  of  the  tuljal  ostia 
(perisalpingitis)  creates  a  barrier  to  subsequent 
fecundity  ("one-child  sterility"),  while  the  associated 
iiutriiional  derangements  induced  in  the  corporeal 
endometrium  disturb  or  inhibit  its  specific  decidual 
function,  with  premature  blight  of  an  existing 
gravidity  ("habitual  abortion"). 

The  direct  spermatocidal  effect  of  a  diseased  cer- 
vical mucosa  is  vividly  depicted  by  Reynolds,  who, 
utilizing  Hiihner's  postcoital  method  for  the  observa- 
tion of  spermatozoa  aspirated  from  the  cervical  cavity, 
states:  "It  is  extremely  interesting  to  see  how 
actively  mobile  spermatozoa  progress  across  the  field 
of  the  microscope  in  a  cervical  secretion  of  grossly 
normal  appearance,  until  they  come  in  contact  with 
some  clumps  of  pus-cells,  with  which  the  tail  of  the 
spermatozoon  becomes  entangled.  The  result  then  is, 
that  it  indulges  in  futile  struggles  to  escape,  by  the 
violence  of  which  it  becomes  exhausted,  and  in  a  few 
minutes  gives  up  the  struggle  and  lies  still." 

The  sterilit}^  of  women  with  "conical  cervix", 
''cervical  flexion",  or  ''pin-hole  os"  is  never  due  to 
the  cervical  malformation  as  such,  but  to  an  existing 
endocervicitis. 

An  OS  that  oft'ers  sufficient  egress  for  millions  of 
blood-cells  during  every  menstruation  will  readily 
afford  ingress  to  a  spermatozoon  whose  diameter 
measures  less  than  that  of  a  single  red  corpuscle. 
AA^e  constantly  encounter  fecundity  in  cases  of  "pin- 
hole os",  and  sterility  in  widely  gaping  lacerated 
cervices,  when  the  latter  are  infected. 


52  GYNECOPLASTIC   TECHNOLOGY. 

The  cervical  mucosa  was  characterized  in  the 
foregoing  as  the  uterine  tonsil;  this  pathogenic 
parallel  finds  its  applicability  when  chronic  endo- 
cervicitis  is  recognized  as  a  primary  infectious  focus, 
and  its  systemic  symptoms  as.  toxic  manifestations. 
The  ambiguous  category  of  the  "reflex  neurosis"  ac- 
companying cervical  disease  is  thus  brought  within 
the  more  lucid  range  of  the  toxicoses  along  modern 
lines  of  clinical  research. 

We  have  learned  to  recognize  systemic  manifes- 
tations from  primary  foci  in  the  mouth,  the  gall-blad- 
der, the  appendix,  the  urethra,  etc.  Why  not  from 
the  cavity  of  the  cervix  ?  Why  term  a  symptom  toxic 
there,  and  neurotic  here?  Who  can  continue  to  be- 
lieve that  "clavus  uterinus"  is  due  to  "pinching  of 
'nerve  terminals'  by  cicatrices  in  the  angle  of  a  cer- 
vical tear"? 

Without  extending  this  detailed  analysis  beyond 
the  cardinal  manifestations  enumerated,  it  would 
appear  sufficiently  evident  that  the  whole  symptoma- 
tology, the  complications  and  sequela  of  chronic  endo- 
cervicitis,  may  be  readily  predicated  from  its  patho- 
logical course  as  outlined  above. 


CHAPTER  VI. 

Etiology  of  Exdocervicitis. 

Infection  of  the  cervix  frequently  dates  back  to 
a  vulvitis  in  early  infancy.  This  significant  fact  illu- 
minates many  of  the  gynecological  disturbances  in 
viro'ins. 


Fig.  17.— Infantile  endocervicitis — "Vulvovaginitis."  Round-cell 
infiltration  of  the  intramuscular  connective  tissue  from  a  case  of 
gonorrheal  vaginitis. 


Hess  reports  the  posf-morfciii  findings  in  four  in- 
fants that  had  the  usual  non-virulent  form  of  ''vagi- 
nitis" during  periods  ranging  from  "three  weeks  to 
one  year  or  more,  in  all  of  which  the  onlv  abnormal 

'  (53) 


54 


GYNECOPLASTIC   TECHNOLOGY. 


condition  and  sole  lesion  was  an  inflammation  of  the 
cervix,  with  round-cell  infiltration  of  its  submucous 
tissue."   On   the   basis   of  these  findings   Hess   con- 


Fig.  18. — Chronic  endocervicitis.  Section  from  a  cervix  after 
repeated  cauterizations.  Benign  proliferation  of  the  epithelium  in 
the  gland  lumen,  with  epidermization  of  the  surface.     (Abel.) 


ETIOLOGY  OF  ENDOCERVICITIS. 


55 


eludes  that  "we  must  regard  the  average  gonococcus 
infection    as    invohang   the    cervix    rather    than   the 


Fig.  19. — Chronic  endocervicitis.  Section  of  a  so-called 
"erosion"'  of  the  cervix,  showing  transition  from  columnar  to 
squamous  epithelium,  a,  Squamous  epithelium  broken  at  h  by 
vulsellum.  c,  Columnar  epithelium  proliferating  over  the  area  nor- 
mally covered  by  squamous  epithelium,  d,  Glandular  depressions 
extending  under  the  proliferating  squamous  epithelium,  e,  Stroma 
infiltrated  with  round  cells.     (Abel.) 

vagina,  and  must  consider  the  infection  a  cervicitis 
rather  than  a  vaginitis." 

In  adult   females,   ]\Ienge  estimates   that  95   per 


56  GYNECOPLASTIC   TECHNOLOGY. 

cent,  of  chronic  gonorrheal  infections  are  located 
within  the  cervix. 

While  the  gonococcus  is  by  far  the  most  frequent 
provocative  organism  in  chronic  endocervicitis,  strep- 
tococcic, staphylococcic,  and  colon  bacillus  infections 
are  not  at  all  infrequent  findings  in  the  order 
enumerated. 

In  infants,  the  exanthemata — and  especially  scar- 
let fever,  protracted  diarrheas,  with  probable  con- 
tamination from  soiled  diapers,  and  general  debili- 
tating conditions — seem  to  confer  a  special  suscep- 
tibility to  cervical  infections;  while  in  adults,  con- 
genital maldcA^elopment  of  the  cervix — and  more 
especially  when  traumatized  by  cauterizations,  dila- 
tations,   curettage    or    birth    injuries — embodies    the 

Description  of  Plate  IV. 

A,  obj.  3,  oc,  3,  tub,  20.  Heemalaun.  Diagnostic  excision.  An  area 
at  some  distance  from  the  erosion  showing  an  extension  of  the  round- 
celled  infiltration  under  the  squamous  epithelium  and  a  death  of  the 
basal  layer  of  cells. 

B,  obj.  3,  oc,  I,  tub,  20.  Hsemalaun.  Uterus  removed  because  of 
retroflexion  with  adnex-tumors  and  adhesions.  This  patient  had  a 
purulent  vaginal  discharge.  Eversion  was  present,  and  there  was  an 
"erosio-glandularis,"  with  marked  round-celled  infiltration  around  the 
glands.  The  area  shown  is  at  some  distance  from  the  erosion  and 
shows  what  might  be  interpreted  as  a  beginning  erosion,  caused  by  the 
inflammation  and  round-celled  infiltration  excited  by  an  infected  gland. 

C,  obj.  I,  oc,  4,  tub,  15.  Haemalaun.  Showing  two  communications 
of  a  gland  with  the  surface.  Round-celled  infiltration,  though  slight, 
is  present  around  the  openings  of  the  glands.  At  one  of  the  orifices 
there  is  apparently  a  destruction  of  the  basal  squamous  cells. 

D,  obj.  DD,  oc,  3,  tub,  0.  Hsemalaun.  Drawing  from  an  "erosio- 
glandularis"  which  is  healing.  The  basal  cells  are  shown  exposed  as  a 
form  of  columnar  epithelium.  This  same  preparation  showed  true 
cylindric  epithelium  on  the  surface. 

E,  obj.3,  oc,  T,tub,  15.  Hasmalaun  and  muci-carmine.  Nullipara.  Myoma- 
tous uterus.  Shows  the  squamous  epithelium  growing  under  the  cervi- 
cal epithelium,  which  shows  the  characteristic  staining  with  muci-carmine. 

F,  obj.  I,  oc,  4,  tub,  16.  Hsemalaun  and  muci-carmine.  Glandular 
cells  show  the  characteristic  staining  reaction  for  mucin.  The 
squamous  epithelium  has  grown  into  the  openings  of  the  glands  under- 
neath their  epithelium. 

G,  obj.  I,  oc,  4,  tub,  18.  Haemalaun.  Diagnostic  excision.  Squamous 
epithelial  plug  connected  with  the  surface.  Near  it  is  seen  a  small 
cj'st  lined  with  low  cylindrical  epithelium.      (Adair.) 


PLATE  IV. 


T^*ffe*C--i. 


e^^^S^^ 


^..J^ 


iir^'"^" 


'"'^*^H>'    /»'»^*"'V**^ 


-■^•K,, 

-    -        -^O. 


"^^^ 


Histopathology  of  "cervical  erosion." 


ETIOLOGY  OF  EXDOCERVICITIS. 


57 


most    prolific   predisposing   factor    to    chronic   endo- 
cervical  disease. 

The  objective  features  of  chronic  endocervicitis 
are  typical,  and  plainly  evident  on  inspection.  The 
nullipara  complaining  of  dysmenorrhea  and  sterility, 
with  her  conical  cervix  showing  its  inflammatory 
halo  encircling  a  small  pouting  os  extruding  a  ten- 


Fig.  20. — "Infantile  erosion" — Chronic  endocervicitis.  Sharp 
demarcation  between  proliferating  squamous  epithelium  and  col- 
umnar cells.  A,  Squamous  epithelium.  B,  Columnar  cells.  C, 
Blood-vessels.     (Chrobak  and  Rosthoni.) 


acious  clump  of  mucus;  or  the  multipara,  with  lacer- 
ated, eroded  h3'-pertrophied  lips,  honeycombed  with 
nabothian  cysts  under  a  granular  surface  that  bleeds 
on  the  slightest  touch — all  of  these,  in  their  varying 
degrees  of  intensity,  constitute  a  clinical  picture  so 
familiar  as  to  call  for  no  detailed  delineation. 


CHAPTER  VII. 

Treatment  of  Chronic  Endocervicitis. 

The  inadequacy  of  prevailing  therapeutic  meas- 
ures in  the  treatment  of  chronic  endocervicitis  offers 
the  most  convincing  evidence  of  misleading  funda- 
mental concepts.  Who,  among  the  most  experienced, 
does  not  realize  his  inability  to  cure  permanently  the 
ordinary  leucorrhea  of  cervical  disease? 

Chronic  endocervicitis  is  primarily  and  essentially 
an  infection  of  the  deeply  situated  terminal  tufts  of 
the  endocervical  muciparous  glands.  These  glandu- 
lar saccules  harbor  the  infecting  organisms  for  years 
or  a  lifetime.  Their  distention  from  duct  occlusions 
may  honeycomb  the  cervical  tissues  with  so-called 
nabothian  cysts,  or,  becoming  purulent,  riddle  the 
cervix  with  chronic  miliary  abscesses,  as  shown  in 
Fig.  23. 

It  is  an  axiomatic  surgical  principle,  in  the  control 
of  any  infectious  process,  to  direct  the  therapeutic  aim 
at  the  primary  focus  of  infection.  In  general  and 
specialistic  practice,  the  escharotic,  the  dilator  and  the 
curette  still  hold  sway  as  established  routine  meas- 
ures, especially  for  the  chronic  endocervicitis  in  the 
nuUiparous. 

Mild  escharotics  and  discriminate  dilatation,  by 
promoting  drainage,  may  prove  of  some  benefit  in  very 
superficial  infections,  but  curettage  cannot  he  too 
emphatically  condemned  in  any  case.  The  curette 
does  not  and  cannot  reach  the  deeply  situated  infected 
(58) 


TREATMEXT  OF  CHRONIC  EXDOCERVICITIS. 


59 


racemose  tufts  of  the  muciparous  glands  in  the  cer- 
vical tissues.  Moreover,  it  should  not  injure  the 
utricular  tubules  of  the  corporeal  endometrium,  which 
is  rarely  if  ever  involved  in  the  disease,  and  whose 
specific  functions  in  menstruation  and  gestation  have 
been  permanently  vitiated  by  the  laceration  and  inocu- 
lation   incidental    to    this    time-honored    traumatism. 


Fig.  21. — Chronic  endocervicitis.     Dense  round-cell  infiltrations  in 
the  subepithelial  layers  and  muscular  stroma  of  the  cervix. 


Tlie  corporeal  cndoiiictriuin  is  a  highly  specialised 
tissue,  to  be  assiduously  conserz'ed,  and  not  to  he  har- 
rozved  and  scraped  zvith  impunity.  The  cases  of  posi- 
tive corporeal  endometritis  will  be  found  among  uteri 
that  have  been  cauterized  or  scraped  from  one  to 
several  times. 

In  the  parous  cervices  with  infected  lacerations, 
the  symptoms  emanate  from  the  infection,  and  not 


60  GYNECOPLASTIC   TECHNOLOGY. 

from  the  rent  in  the  cervix.  Nevertheless,  surgeons 
usually  take  cognizance  of  the  rent  and  ignore  the 
infection,  with  the  resulting  proportion  of  ultimate 
failures  tabulated  in  Leonard's  statistics  quoted  above. 
Similar  failures  have  prompted  many  surgeons  to 
desist   from  all   tracheloplastic   attempts   during  the 


Fig.  22. — Chronic  endocervicitis.     Dense  round-cell  infiltration  in 
the  subepithelial  layers  and  muscular  stroma  of  the  cervix. 

child-bearing  period,  preferring  to  shut  their  eyes  to 
the  existing  condition  rather  than  incur  failure  to 
cure,  or  possible  aggravation,  by  standardized  pro- 
cedures of  questioned  efficacy. 

To  cure  chronic  endocervicitis,  we  must  remove 
the  entire  infected  area  of  the  endocervical  mucosa; 
as  long  as  endocervicitis  persists,  so  long  will  its 
symptoms  persist. 


TREATMENT  OF  CHRONIC  ENDOCERVICITIS. 


61 


The  operation  of  Iraehelorrhaphy  was  originally 
evolved  from  the  misconception  that  the  local  and  gen- 
eral manifestations  following  laceration  of  the  cervix 
are  due  solely  to  gaping  flaps,  with  cicatricial  dis- 


Fig.  23. — Chronic  endocervicitis,  with  niiUary  abscesses.  Sec- 
tion through  cervix ;  subepithelial  inflammatory  foci ;  hyperplastic 
lymph-vessels,  with  streaks  of  round-cell  infiltration  and  small  in- 
flammatory foci  in  the  cervical  musculature.  A,  Blood-vessel.  B, 
Muscle-bundle.  C,  Lymph-vessel.  D,  Squamous  epithelium.  E, 
Miliary  abscess. 


tortion,  and  that  a  cure  of  the  condition  demanded 
nothing  more  than  excision  of  the  cicatrix,  and  sutural 
closure  of  the  gap.     In  other  words,   the  operator 


62 


GYNECOPLASTIC    TECHNOLOGY. 


aimed  to  reproduce  the  original  area  of  laceration 
and  reunite  its  edges. 

It  is  obvious  that  the  airative  scope  of  this  pro- 
cedure is  necessarily  limited  to  the  cases  in  which  the 
infection  has  not  extended  beyond  the  lines  of  the 


Fig.  24. — Cancerous  endocervical  gland,  a,  Dark  globular  cell 
infiltrate,  h,  Normal  columnar  epithelium  separated  from  its  base 
at  d.    c,  Carcinoma  involving  the  right  wall  of  gland.     (Abel.) 


original  tear — a  rare  condition,  for  we  know  to-day 
that  the  functional  disturbances  following  lesions, 
which  demand  surgical  intervention — that  is,  the  in- 
fected tears — signalize  the  infectious  invasion  of  the 


TREATMENT  OF  CHRONIC  ENDOCERVICITIS. 


63 


entire  length  and  l)rcadth  of  the  cervical  mucosa,  from 
external  to  internal  os,  and  that  the  conservation  of 
the  invaded  area  within  the  cervical  canal  beyond  the 
lacerated  edges  perpetuates  the  whole  pathological 
process. 

If  this  is  true  of  single  tears,  it  applies  with  pro- 
portionately   greater    force   to    multiple   tears.      But 


Fig.  25.— Carcinoma  of  the  cervix.  Primary  stage,  a.  Squamous 
epithelium,  b.  Artefacts.  C,  Cancer  nodules,  dj  Cancer  pearls. 
(Abel.) 


whether  we  accept  or  reject  the  foregoing  considera- 
tions as  valid  factors  in  limiting  the  scope  of  secon- 
dary trachelorrhaphy  as  a  curative  measure,  a  more 
sinister  menace  obtrudes  itself  into  this  question  to- 
day, namely,  the  enhanced  cancerous  potentialities  in 
the  chronically  inflamed  cervical  areas  beyond  the 
range  of  the  Emmet  operation. 

A  recent  publication  by  Ewing,  on  precancerous 
diseases,  affirms  that  "chronic  catarrhal  endocervicitis 
precedes    cancer    in    the    great    majority    of    cases 


64  GYNECOPLASTIC   TECHNOLOGY. 

and  the  cervical  erosion  is  the  most  defi- 
nitely established  lesion  known  to  initiate  cervical 
carcinoma."  Polese  demonstrated  this  in  34  out  of 
48  cases.  Beckman  carefully  observed  the  develop- 
ment of  carcinoma  in  an  erosion  which  he  treated  for 
five  years. 

Early  stages  of  carcinoma  from  such  lesions  are 
described  by  Waldeyer,  Ruge,  and  Veit,  by  Cullen, 
Schauenstein,  Sitzenfrey,  and  others.  Ewing  studied 
three  instances  of  precancerous  poh^p  in  eroded  cer- 
vices showing  metaplastic  overgrowth  and  beginning 
invasion  of  the  stroma  by  adenocarcinoma. 

Aside  from  these  clinical  considerations,  many 
gynecologists  have  for  a  long  time  discarded  trache- 
lorrhaphy in  the  majority  of  their  cases  on  purely 
technical  grounds.  Thus,  Noble  declares  that  "in  cer- 
vical lacerations  of  long  standing,  with  marked  hyper- 
trophy and  nabothian  cystic  degeneration,  amputation 
is  to  be  preferred,  as  the  conditions  left  by  trachelor- 
rhaphy are  far  from  satisfactory,  and,  furthermore, 
that  all  cervices  deficient  in  bulk  from  underdevelop- 
ment, irregular  multiple  tears,  or  previous  sloughing 
present  insufhcient  tissue  for  normal  reconstruction 
by  trachelorrhaphy." 

The  foregoing  arraignment  of  this  procedure,  on 
physiological,  pathological,  clinical,  and  technical 
grounds,  forces  the  conviction  that  late  trachelor- 
rhaphy, whenever  indicated,  must  prove  inefficacious 
as  a  curative  measure,  and  when  apparently  curative 
was  probably  superfluous. 

With  the  cervical  lesion  as  the  established  portal 
of  infection,  simple  trachelorrhaphy  should  find  its 
cardinal  and  practically  its  only  sphere  early  in  the 


PLATE  V. 


Healed  non-infected  bilateral  laceration. 


Mild   endocervicitis.      Bilateral    laceration. 


PLATE  VI. 


V^irainal  chronic  endocervicitis.     Conical  cervix. 


PLATE  VII. 


Virginal  chronic  endocervicitis  with  "erosion." 


Chronic  endocervicitis,  with   mild   manifestation  at 
the  external  os   (leucorrhea). 


PLATE  \'III. 


A,  Gonorrheal  condylomata.     B,  Gonorrheal 
endocervicitis. 


PLATE  IX. 


y 


Chronic  senile  endocervicitis.    Infected  bilateral  laceration,  with 
extreme  relaxation — "eversion" — of  the  cervical  wall. 


Chronic  endocervicitis.     Mildly  infected. 
Stellate  laceration. 


PLATE  XI. 


Chronic  endocervicitis.    Infected  laceration  with  "ulceration 
and  suppurative  nabothian  folliculitis." 


Chronic  endocervicitis.     Infected  laceration.     "Ectro- 
pium  with  follicular  suppuration." 


PLATE  XII. 


) 


Chronic  endocervicitis.     Infected  laceration,  with  "'gran- 
ular  erosion"  and  nabothian   folHcuIitis. 


$y 


Chronic  endocervicitis,  with  mucous  polipi. 


Pr.ATE  XI IT. 


Chronic  endocervicitis,  with  carcinomatous  papilloma. 


-Stf 


Endocervical  carcinoma  in  the  initial  stage. 


PLATE  XIV. 


Chronic  endocervicitis,  with  carcinomatous  ulceration. 


Carcinoma  of  cervix,  with  sloughing  into  the 
posterior  vaginal  vault. 


PLATE  XV. 


m 


Carcinoma  of  cervix,  with  endocervical  necrosis. 


Endocervical  carcinoma  in  section,  showing  its  tendency 
to  progress  along  the  uterine  musculature,  rather  than  by  way 
of  the  corporeal  endometrium. 


TREATMENT  OE  CHRONIC  ENDOCERVICITIS. 


65 


puerperiuni,  Avhen  "iinniediatc,"  or,  still  better,  the 
''intermediate"  operation  represents  an  efifort  of  the 
highest  prophylactic  potency. 

In  thus  restricting-  the  applicability  of  trachelor- 
rhaphy to  the  puerperium,  we  necessarily  augment  the 


Fig.  26. — Advancing-  carcinoma  of  cervix.     Note  involvement 
of  the  uterine  musculature. 


range  of  cervix  amputation  as  the  reparative  method 
of  choice  for  all  chronic  cervical  lesions;  and  it  now 
remains  to  elucidate  and  obviate  as  far  as  possible 
those  derangements  noted  after  this  more  radical 
operation. 

In  the  light  of  the  normal  and  pathological  funda- 
mentals at  hand,  both  cause  and  prevention  of  these 


66 


GYNECOPLASTIC   TECHNOLOGY. 


postoperative  disturbances  are  revealed  as  inherent  in 
the  technique  of  the  prevaihng  methods  of  cervix 
amputation. 

A  low  amputation  of  the  cervix  is  a  partial  ampu- 
tation, and  can  only  eliminate  a  part  of  its  diseased 


Fig.  27. — Advanced  carcinoma. 


mucosa,  while  a  complete  or  high  amputation  is  an 
unwarrantable  mutilation  of  its  muscular  mechanism. 
When  a  cervix  tears  during  labor,  the  rent  extends 
practically  in  the  direction  of  its  muscle-fibres.  On  the 
other  hand,  when  the  cervix  is  amputated  in  the  usual 
manner,  the  muscle-fibres  are  severed  transversely. 
The  spontaneous  tear,  unless  infected,  exercises  but 


PLATE  XVT. 


Sj'philitic  ulcer  in  angle  of  laceration. 


TREATMENT  OF  CHRONIC  EXDOCERVICITIS. 


67 


Fig.  28. — Tracheloplasty  (author's  method).  Outhning  the  edge 
of  the  flap  on  the  vaginal  sheath  of  the  cervix  along  the  demar- 
cating line  between  the  normal  vaginal  and  diseased  endocervical 
mucosa  in  a  case  of  infected  bilateral  laceration. 


68  GYNECOPLASTIC   TECHNOLOGY, 


Fig.  29. — Tracheloplasty  (author's  method).  Elevating  the 
flap  edge  preparatory  to  its  free  mobilization  by  blunt  dissection 
from  the  subjacent  musculature. 


PLATE  XVII. 


Tracheloplasty  (author's  method).  Outlining  the  edge  of  the 
flap  of  the  vaginal  sheath  of  the  cervix  along  the  demarcating 
line  between  the  normal  vaginal  and  the  diseased  endocervical 
mucosa  in  a  case  of  nuUiparous  chronic  endocervicitis. 


TREATMEXT  OF  CHRONIC  EXDOCERVICITIS.  69 

little  influence  upon  the  muscular  mechanism  of 
the  cervix,  while  the  transverse  ablation  detroys  it 
completely. 

Circular  amputation  of  the  cervix,  and  union  of 
its  vaginal  and  endometrial  mucosa,  according  to 
standard  methods,  defeats  its  own  purpose  by  dis- 
regarding the  physiological  and  textural  characters 
of  the  cervical  tissues. 

According  to  an  established  law^  in  myodynamics 
— "the  extent  of  contractile  shortening  in  a  given 
muscle  depends  upon  the  arrangement  and  number  of 
its  contractile  tmits" — the  longer  the  muscle,  the 
greater  the  number  of  its  contractile  units.  Conse- 
quently, a  long  muscle-bundle  will  contract  through  a 
proportionately  w"ider  interval  than  a  similarly  ar- 
ranged short  one. 

In  the  uterus  the  peripheral  fibres  traversing  the 
greater  circumferential  area  are  necessarily  much 
longer  than  the  central  fibres  that  entw'ine  the  uterine 
cavity.  It  follows,  therefore,  that  on  ablating  the 
cervix  in  the  usual  manner,  all  the  muscle  stumps  are 
made  to  terminate  at  the  same  level.  The  longer 
peripheral  fibres,  contracting  to  a  higher  plane  than 
the  shorter  central  fibres,  tend  to  pull  the  vaginal  and 
endometrial  margins  of  the  stump  asunder.  Further- 
more, the  extreme  friability  of  the  endometrial  edge 
renders  its  sutural  retention  purely  transitory,  so  that 
sooner  or  later  the  flaps  separate  and  expose  a  raw 
beveled  cervical  stump. 

These  exposed  stump  surfaces  heal  by  granulation. 
Some  never  heal  completely;  but  when  they  do,  and 
the  patient  comes  to  child-birth,  the  annular  cicatrix, 
incapable  of  physiologic  retractile  expansion,  presents 


70 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  30. — Tracheloplast)'    (author's  method).     Mobilization  of  the 
cylindrical  vaginal  flap  to  the  vaginal  fornices. 


TREATMENT  OF  CHKOXIC  ENDOCERVICITIS.  71 


Fig.  31. — Trachcloplasty  (author's  method).    Excision  of  endocer- 
vical  cone,  the  knife  directed  towards  the  internal  os. 


72 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  32. — Tracheloplasty  (author's  method).  Denuded  funnel  of 
cervical  muscularis,  excised  cone  of  endocervical  mucosa,  and  loose 
cylindrical  flap  of  vaginal  mucosa. 


TREATMENT  OF  CHROXIC  EXDOCERVICITIS.  7Z 

the  dystocia  noted  in  Leonard's  tedious  deliveries. 
The  cases  that  do  not  heal  present  a  raw  area,  which, 
becoming-  infected,  practically  re-establishes  the  origi- 
nal lesion,  with  the  whole  train  of  objective  and 
subjective  disturbances  that  first  prompted  our  sur- 
gical intervention. 

Realizing-  some  of  these  operative  shortcomings, 
Karl  Schroeder  excised  the  cervical  mucosa  separ- 
ately from  the  anterior  and  posterior  lip  as  a  trans- 
verse wedge.  Then  he  folded  each  lip  upon  itself,  and 
sutured  its  vaginal  margin  at  or  near  the  internal  os, 
while  the  redundant  lateral  edges  were  sutured  to  each 
other.  Commenting  on  this  modification,  Noble  states : 
"Schroeder's  operation  accomplishes  the  purpose  of 
removing  the  glandular  portion  of  the  cervix,  but  it  is 
difficult  of  performance,  and  yields  inferior  results." 

Howard  Kelly  removes  a  wedge  of  tissue  from 
each  lateral  angle  after  amputating,  aiming  to  produce 
"a  wide,  smooth  os."  The  method  is  comparable  to 
the  cupping  of  the  cervix  after  supravaginal  hysterec- 
tomy. The  ultimate  outcome  of  this  method,  as 
already  cjuoted  in  our  introductory  statistics,  was 
declared  by  Leonard  as  "quite  unexpected,  and  in 
many  ways  disappointing." 

The  difficulty  in  all  the  prevailing  methods  of 
cervix  amputation  is  encountered  when  suture  of  the 
vaginal  to  the  endometrial  edge  is  attempted,  the 
extreme  friability  and  inaccessibility  of  the  latter  fre- 
quently rendering-  accurate  approximation  and  per- 
manent retention  quite  impossible. 

Briefly  stated,  the  cure  of  a  chronic  endocervicitis, 
whether  in  the  nulliparous  or  multiparous  cervix, 
demands : 


74 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  33. — Tracheloplasty  (author's  method).  Silkworm  strand 
passed  transversely  through  the  vaginal  surface  of  the  anterior 
flap  segment,  Vs  of  an  inch  from  the  edge,  embracing  yg  of  an 
inch  of  tissue. 


TREATMENT  OF  CHRONIC  ENDOCERVICITIS. 


/o 


S  H. 

3  ^ 

5  ^ 

O  (J 

-^3  -J 

^  '-' 

™  a; 
u 

''3  ^ 

o  ^ 


Ph 


u^ 


( 1 )  Complete  enu- 
cleation of  the  entire 
endocervical  mucosa, 
from  external  to  inter- 
nal OS,  with  preserva- 
tion of  its  muscular 
structure. 

(2)  Accurate  re- 
lining  of  the  denuded 
cervical  canal  by  a  cy- 
lindrical cuff  of  its  vagi- 
nal sheath. 

The  following  me- 
thod fulfills  the  physio- 
logical demands,  meets 
the  pathological  indica- 
tions, and  obviates  the 
technical  shortcomings 
enumerated.  The  pro- 
cedure is  applicable  to 
infected  nulliparous  or 
multiparous  cervices 
alike,  and  comprises: 

( 1 )  Outlining  and 
free  liberation  of  an 
ample  cuff  of  mucosa 
from  the  vaginal  sheath 
of  the  cervix. 

(2)  Enucleation  of 
the  entire  endocervical 
mucosa  to  the  internal 
OS,  with  preservation  of 
its  surrounding  muscu- 
lar layer. 


7(i 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  35.— Tracheloplasty  (author's  method).  Introducing  the 
right  free  suture-end  into  and  slightly  above  the  internal  os  on  a 
double  curved  needle,  v^^hence  it  is  passed  upward,  forward  and 
slightly  to  the  right  through  the  musculature  to  emerge  at  the 
base  of  the  flap  in  the  anterior  vaginal  fornix,  %  of  an  inch  from 
the  median  line. 


TREATMENT  OF  CHRONIC  ENDOCERVICITIS.  77 


Fig.  36. — Tracheloplasty  (author's  method).  Needle,  carrying 
the  right  free  end  of  the  anterior  suture,  emerging  on  the  anterior 
vaginal  fornix  at  the  base  of  the  flap. 


78 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  Zl . — Tracheloplasty  (author's  method).  The  left  free 
suture-end  passed  in  a  direction  iTpward,  forward,  and  to  the  left. 
Both  ends  emerging  on  the  anterior  vaginal  fornix  at  the  base  of 
the  flap,  Yz  of  an  inch  from  the  median  line. 


TREATMENT  OF  CHROXIC  EXDOCERVICITIS.  79 

(3)  Sutural  inversion  of  the  vai^'inal  cuff  into  the 
denuded  cervical  cavity. 

The  main  object  in  the  first  step  is  the  formation 
of  an  ample  cuff  of  mucosa  from  the  vaginal  sheath 
of  the  cervix.  With  this  in  view,  an  outlining  incision 
is  made  to  encircle  the  eroded  area  around  the  external 
OS,  closely  skirting  the  demarcation  border  between 
the  healthy  vaginal  and  the  diseased  endocervical 
mucosa,  running  parallel  to  any  indentations  that 
mark  the  lines  and  angles  of  laceration. 

The  cylindrical  flap  thus  outlined  is  freely  liber- 
ated from  the  anterior  and  posterior  surface  of  the 
cervix  to  the  level  of  the  internal  os. 

The  eroded  external  os,  with  its  everted  hyper- 
trophied  lips,  and  the  entire  cervical  lining  up  to  the 
internal  "os,  are  now  cored  out  of  the  surrounding- 
muscular  bed  as  a  complete  cone. 

In  congenitally  deformed  nulliparous  cervices, 
chronicall}^  infected,  the  muscular  framework  thus 
exposed  may  now  be  advantageously  reshaped  by 
appropriate  incisions  on  the  lines  established  by 
Sims,  Pozzi,  or  Dudley,  according  to  indication  or 
predilection. 

The  vaginal  flap  is  not  included  in  any  of  these 
muscle  incisions,  to  which  no  individual  stitches  need 
be  applied. 

The  cervix  now  presents  a  muscular  funnel  within 
a  deep  cylindrical  sheath  of  vaginal  mucosa.  The 
inversion  of  the  cylindrical  sheath  of  vaginal  mucosa 
into  the  muscular  funnel,'  and  its  sutural  coaptation  at 
the  correct  level,  is  accomplished  in  the  following 
manner :  Beginning  with  the  anterior  segment  of  the 
circular  flap,  a  long  strand  of  heavy  silkworm  gut  is 


80 


GYNECOPLASTIC    TECHNOLOGY. 


Fig.  38. — Tracheloplasty  (author's  method).  Traction  on  the 
two  anterior  suture  ends  draws  the  anterior  vaginal  flap  segment 
into  the  cervical  cavity,  and  approximates  its  edge  to  the  circum- 
ference of  the  denuded  internal  os. 


PLATE  X\'Iir. 


Tracheloplasty  (author's  method).  Schematic  sagittal  A-iew 
of  the  suture  course  in  the  anterior  flap  segment.  A,  Edge 
of  the  cyhndrical  vaginal  flap.  B,  Edge  of  denuded  cervical  cavity. 
C,  Course  of  suture  through  the  musculature  to  the  base  of  the 
vaginal  flap.  The  suture  of  posterior  flap  segment  runs  parallel 
to  that  of  the  anterior,  but  in  a  correspondingly  posterior  direction. 


82 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  39. — Tracheloplasty  (author's  method).  The  anterior  and 
posterior  sutures  drawn  taut  and  tied,  flap  in  place,  lining  the  cer- 
vical cavity  to  the  internal  os. 


TREATMENT  OF  LllKUXIC  EXDOCERVICITIS.  83 

cavity  will  foreshorten  the  anterior  vai2;'inal  wall,  and 
tilt  the  uterus  backward. 

To  lengthen  a  congenitally  foreshortened  anterior 
vaginal  wall,  as  suggested  by  Reynolds,  it  is  only 
necessary  to  incise  the  anterior  flap  segment  trans- 
versely and  pull  this  transverse  incision  into  a  longi- 
tudinal slit  before  passing  the  main  sutures,  which, 
emerging  at  the  sides  of  the  slit,  coapt  and  retain  its 
edges  in  the  longitudinal  axis. 

Additional  sutures  are  usually  imnecessary.  The 
silkworm  ends  are  left  long  to  facilitate  their  removal, 
and  tucked  into  the  vagina. 

A  narrow  strip  of  iodoform  gauze  introduced  into 
the  cervix,  with  the  object  of  maintaining  flat  coapta- 
tion of  all  raw  surfaces,  completes  the  operation. 

This  gauze  is  removed  on  the  third  or  fourth  day, 
when  the  patient  is  permitted  to  walk  about. 

The  stitches  are  removed  at  the  end  of  the  third 
week,  when  they  will  be  found  loose  and  accessible. 

The  specific  features  of  the  operative  method  thus 
outlined  efl:"ect  the  complete  elimination  of  the  infec- 
tious focus  by  extirpation  of  the  diseased  cervical 
mucosa;  preserve  the  normal  arrangement,  contour, 
and  functions  of  the  cervical  musculature ;  obviate  the 
mechanical  difficulty,  and  secure  the  permanency  of 
accurate  sutural  coaptation  of  flap  to  stump. 

I  do  not  claim  an  ideal  restitution  to  the  normal 
in  all  cases.  So  perfectly  a  balanced  mechanism  as  the 
uterus,  when  once  deranged,  cannot  be  perfectly  re- 
stored by  surgery.  But  I  may  contend  that  the  pro- 
cedure here  advocated  obviates  in  the  greatest  number 
of  cases  the  detailed  shortcomings  in  the  prevailing 
tracheloplastic  methods  and  results. 


CHAPTER  VIII. 

The  Cervicoplastic  Treatment  of  Sterility. 

In  its  clinical  designation,  the  term  sterility  is 
purely  relative,  necessarily  implying  in  a  given  case 
the  presence  of  approximately  normal  anatomic  and 
physiologic  essentials  to  conception,  without  the 
consummation  of  offspring.  Physiologically,  every 
woman  who  menstruates,  ovulates.  Biologically,  ovu- 
lation predicates  potential  fecundity.  The  virgin 
ovary  harbors  from  forty  to  sixty  thousand  ova. 
Ovulation,  fertilization,  and  nidation  constitute  the 
chronological  cycle  of  conception,  and  any  perversion 
in  their  normal  concurrence  determines  sterility.  We 
cannot  create  a  function;  we  can  only  attempt  to 
activate  one  existing  in  a  dormant  state,  stimulate  one 
deficient,  or,  possibly,  mobilize  one  tentatively  in- 
hibited. The  maturation  of  a  graafian  follicle  and 
liberation  of  its  contained  ovum,  the  evolution  of  the 
corpus  luteum,  the  endometrial  transmutation  essen- 
tial to  deciduation,  the  subtle  biotactic  elements  that 
dominate  ovular  fertilization  and  nidation,  are  all  sus- 
ceptible to  inhibiting  influences,  temporary  or  per- 
manent, local  or  systemic,  most  of  which  involve 
problems  far  beyond  our  present  diagnostic  horizon 
and  therapeutic  scope. 

Who  can  explain  why  the  conjugation  of  a  per- 
fectly normal  female  with  an  equally  normal  male 
proves  sterile,  while  the  subsequent  union  of  each 
with  another  demonstrates  the  fecundity  of  both?  To 
(84) 


CERVICOPLASTIC  TREATMENT  OF  STERILITY.         85 

apply  the  serological  hypothesis  of  "a  selective  ovular 
immunity  to  certain  strains  of  sperma"  in  explanation, 
is  mere  terminological  juggling.  Fecundity  is  a  ques- 
tion of  seed  and  soil.  We  cannot  control  the  seed; 
we  can  onl\-  enhance  its  viability  by  correcting  a  defi- 
cient soil.  W't  cannot  control  the  ovule;  we  can  only 
aim  to  correct  certain  endometrial  abnormalities  in- 
imical to  its  fertilization  and  nidation. 

The  endometrium  must  provide  a  medium  condu- 
cive to  the  virility  and  progression  of  the  sper- 
matozoon in  its  fertilizing  mission,  and  must  respond 
normally  to  ovular  fertilization,  with  a  concurrent 
activation  of  its  decidual  potentialities  essential  to 
normal  nidation. 

According  to  established  modern  conceptions, 
chronic  corporeal  endometritis  is  extremely  rare.  Our 
former  acceptance  of  the  condition  was  based  upon 
misinterpretations  of  the  normal  endometrial  changes 
characteristic  of  its  menstrual  cycle,  as  already  eluci- 
dated above.  But  for  this  relative  immunity  of  the 
corporeal  endonietriiun,  the  extreme  prevalence  of 
chronic  endocervicitis  would  render  the  largest 
majority  of  women  sterile,  for  a  diseased  ccrvieal 
mucosa  is  capable  of  iuunohilizing  and  destroying 
spermatozoa. 

But  beyond  the  direct  devitalization  of  sperma  by 
the  diseased  cervical  mucosa,  other  factors,  of  equal 
and  greater  potency  in  the  causation  of  sterility,  may 
be  incited  through  the  influence  of  cervical  disease 
upon  the  functions  of  the  uterus  as  a  whole,  for,  zi'Jiile 
chronic  endocervicitis  never  extends  to  the  corporeal 
endonietriuni  by  direct  continuity,  a  sterility  accom- 
panying  the    former    ls'    due    in    large    part    to    the 


86  GYNECOPLASTIC   TECHNOLOGY. 

functional  derangements  induced  in  the  latter.  (See 
chapter  on  Endocervicitis. ) 

Crystallized  into  a  concrete  postulate,  chronic 
endocervicitis  presents  the  key  to  the  therapeutic 
problem  in  sterility  of  cervical  origin,  and  the  success 
of  any  curative  attempt  upon  the  cervix  will  be  pro- 
portionate to  its  elimination  of  an  existing  endo- 
cervical  infection. 

The  question  as  an  abstract  proposition,  whether  a 
tracheloplastic  widening  of  the  cervical  canal  cures 
sterility  by  facilitating  the  ingress  of  spermatozoa,  or 
the  egress  of  deleterious  secretions,  would  appear  of 
more  academic  than  practical  interest,  but  applied  to 
the  individual  case  it  acquires  the  significance  that  dis- 
tinguishes between  rational  procedures  and  empirical 
practice. 

Every  curative  attempt  should  be  based  upon  a 
correct  perception  of  indications,  and  a  definite  realiza- 
tion of  its  aim  and  scope.  Wo.  must  know  why  we 
operate,  in  order  to  determine  when  and  how  to 
operate. 

Boldt  states :  ''Next  to  curetting,  dilatation  of  the 
cervical  canal,  principally  to  overcome  sterility,  is  the 
operation  most  frequently  done  without  proper  indica- 
tion. Those  who  have  made  observations  will  prob- 
ably concede  that  in  75  per  cent,  of  patients  so  treated 
the  intervention  is  unwarranted." 

The  cervicoplastic  operations  in  vogue  for  the 
cure  of  sterility  comprise  the  so-called  discission  and 
amputation — that  is,  the  cervix  is  either  split  or 
ablated. 

]\lany  women  undoubtedly  conceive  after  one  or 
other  of  these  operation,  as  they  occasionally  do  after 


CERVICOPLASTIC  TREATMENT  OE  STERILITY.         87 

dilatation  and  curettage,  but  to  attribute  an  eventual 
fecundity  to  the  curative  effect  of  this  or  that  pro- 
cedure is  an  obvious  "post  hoc"  interpretation;  for  it 
must  be  conceded  that,  on  the  one  hand,  many  women 
presenting-  operative  indications  ultimately  conceive 
without  anv  intervention  w^iatsoever,  while  on  the 
other  hand  a  very  considerable  number  of  operations 
prove  utterly  futile  of  results. 

One  hundred  and  twenty-eight  complete  post- 
operative histories  from  among  400  recorded  cases 
tabulated  by  Leonard  in  Howard  Kelly's  clinic  re- 
vealed 80  per  cent,  of  sterility  after  low  amputation 
for  cervical  lacerations. 

In  other  words,  8  out  of  10  women  of  established 
fecundity  are  sterilized  by  prevailing  methods  of  cer- 
vix amputation ;  and  while  we  recognize  an  occasional 
postpuerperal  sterility  as  a  possible  sequel  of  birth 
injuries  ("one-child  sterility"),  its  occurrence  never 
attains  to  such  proportions. 

The  normal  cervical  lining  is  not  essential  to  con- 
ception or  gestation,  but  a  diseased  lining  is  inimical 
to  both,  and  should  be  removed  by  the  method  advo- 
cated in  the  chapter  on  the  treatment  of  endocervicitis. 

I  would  not  dogmatically  attribute  the  cure  of 
sterility  to  this  operation  any  more  than  to  other  pro- 
cedures, for  there  is  too  much  that  is  unknown  and 
unknowable  involved  in  the  problem;  but  I  may  as- 
sert, after  a  very  extensive  and  critical  trial,  that  the 
method  as  outlined  radically  eliminates  chronic  endo- 
cervicitis— the  one  established  causative  factor  in  the 
sterility  of  cervical  origin.  » 


CHAPTER  IX. 

Perineorrhaphy. 

The  practice  of  perineorrhaphy  dates  from  the 
middle  ages.  Tradition  points  to  one  Trotula,  a 
woman  attached  to  the  school  of  Salernum  in  the 
eleventh  century,  as  the  first  to  suture  a  lacerated 
perineum:  ''Post  modinn  rupturam  intra  anuni  et 
vulvan  tribus  locis  vel  quatuor  suimus  cum  Mo  de 
sericej" 

From  this  remote  record  to  the  present  time,  a 
span  of  nearly  one  thousand  years  encompasses  the 
evolution  of  perineorrhaphy,  every  phase  of  which  is 
linked  with  names  of  the  most  illustrious  surgical  ex- 
ponents, and  with  a  literature  which  offers  the  most 
ancient,  the  most  voluminous,  and  yet  the  most  in- 
complete theme  in  modern  gynecology. 

''To  no  department  of  gynecology,"  wrote  Thomas 
thirty-five  years  ago,  "does  there  attach  more  surgical 
rubbish  which  needs  a  thorough  clearing  away  than 
to  perineorrhaphy." 

Three  years  later  Emmet  inaugurated  what  may 
be  termed  a  renaissance  in  perineorrhaphy,  by  demon- 
strating the  significance  of  the  musculofascial  ele- 
ments in  the  nature  and  repair  of  perineal  injuries. 
Nevertheless,  while  thus  among  the  first  to  recognize 
correct  anatomic  essentials  for  a  reparative  method, 
he  devised  an  operation  the  ultimate  results  of  which 
have  not  tended  to  sustain  that  prestige  among  con- 
temporaneous procedures  bestowed  upon  it  by  the 
(88) 


rERlNEUkkiiAl'ilY.  89 

authoritative  name  of  its  advocate,  for,  after  a  vogue 
of  nearly  three  decades,  Jewett  in  1905  characterizes 
''the  female  perineum  with  its  surgical  problems"  as 
the  "pons  asinoruui  of  the  gynecologist" ;  adding  that 
"the  surgical  anatomy,  the  nature  of  obstetric  injuries 
and  the  rationale  of  their  repair,  are  cjuestions  long 
in  dispute,  and  their  solution  still  remote." 

Irving  S.  Haynes,  on  "The  Anatomic  Basis  for 
Successful  Repair  of  the  Female  Pelvic  Outlet,"  as- 
serts that  "the  treatment  of  pelvic  lacerations  is  in 
sufficient  chaos  to  justify  a  reasonably  careful  review 
of  the  salient  features  of  the  subject." 

In  the  same  vein,  W.  W.  Babcock  pointedly  de- 
picts the  practice  of  perineorrhaphy  in  1909  as  fol- 
lows: "The  methods  of  perineorrhaphy  that  have 
been  chiefly  employed  for  the  last  twenty-five  years 
suggest  more  of  a  mathematical  than  an  anatomic 
basis  for  their  existence.  For  the  most  part,  they 
have  consisted  of  excisions  of  mucous  membrane  from 
the  posterior  vaginal  wall,  having  geometrical  pat- 
terns that  vary  as  do  the  fancies  of  the  dift'erent 
surgeons. 

"In  support  of  the  various  operations,  much  has 
been  written  about  the  laceration  in  the  muscular  and 
fascial  planes,  and  of  the  effectiveness  of  particular 
operations;  yet  one  who  studies  the  work  of  various 
gynecologists  will  be  impressed  by  the  thought  that 
usually  the  precise  anatomic  restoration  of  the  peri- 
neum occurs  only  in  the  theory  of  the  operator,  for 
the  operation  as  a  rule  consists  of  little  more  than  the 
removal  of  an  area  of  mucous  membrane  and  the 
union  of  the  wound  edges.  .  .  .  If  at  times  the 
operator's  needle  is  made  to  sweep  in  various  direc- 


90  GYNECOPLASTIC   TECHNOLOGY. 

tions,  with  the  specification  that  certain  muscles  are 
caught  in  its  grasp,  the  precise  evidence  that  such 
muscles  are  included,  and  especially  any  evidence  that 
the  important  fascial  planes  of  the  perineum  are  re- 
stored, is  rarely  observed." 

The  veteran  Henry  O.  Marcy  concludes  one  year 
later  that  "the  basic  principles  of  the  operation  are 
still  in  a  measure  misunderstood." 

C.  M.  Watson  tersely  epitomizes  the  sum  and 
substance  of  the  whole  problem  by  stating  that  "the 
classic  operations  for  the  secondary  repair  of  the  torn 
or  relaxed  perineum  have  been  successful  only  to  a 
degree;  the  more  extensive  the  injury  to  the  levator 
ani  muscle,  the  less  effective  these  operations." 

The  recognition  of  the  levator  ani  as  the  func- 
tional dominant  and  surgical  objective  in  perineal  in- 
juries is  not  of  recent  date.  In  1884,  B.  E.  Hadra,  of 
San  Antonio,  Texas,  first  propounded  the  operative 
problem  as  it  presented  itself  to  him  at  the  time,  in 
the  following: 

"It  will  be  hazardous  to  cut  through  the  posterior 
vaginal  wall  in  order  to  seek  the  levator  muscles  and 
to  sew  them  together;  still  something  of  this  kind 
must  be  done. 

"I  have  in  view  an  operation  which  was  devised 
by  my  deceased  friend.  Dr.  Dowell,  of  Galveston,  for 
hernia.  I  believe  that  it  will  prove  to  be  the  correct 
procedure,  as  it  promises  reunion  of  the  separated 
muscles,  and  narrowing  of  the  slit,  without  any  in- 
jury to  the  surrounding  organs  and  tissues. 

"I  will  at  the  proper  time  report  more  fully  on  this 
point,  but  for  the  present  would  ask  the  profession  to 
take  the  whole  subject  under  consideration,  and  seek 


PERINEORRHAPHY.  91 

sonic  method  to  remedy  evils  which  as  yet  are  beyond 
onr  control." 

Again,  in  1887,  lladra,  after  experimental  at- 
tempts on  the  cadaver,  and  a  critical  scrutiny  of  con- 
temporaneous methods,  stated:  "A  little  reflection 
will  at  once  demonstrate  that  it  is  not  the  perineum 
which  the  operation  aims  at,  but  the  posterior  vagi- 
nal wall.  .  .  .  Wylie's  operation,  like  Emmet's,  is 
not  a  perineorrhaphy.  .  .  .  It  is  only  the  effect  of 
both  operations  on  the  patulency  of  the  vaginal  out- 
let that  makes  them  appear  a  remedy  in  a  ruptured 
perineum.  .  .  .  Very  likely  a  sewing  of  the  margins 
of  the  levator  shanks  sometimes  happens  without  our 
knowledge  in  operations  where  the  sides  of  the  vagina 
are  extensively  denuded,  so  as  to  lay  the  muscles 
bare.  ...  I  am  confident  that,  in  all  the  colporrha- 
phies  which  have  given  permanent  relief,  the  shanks 
of  the  levator  were  united  to  each  other  on  the  sides 
of  the  vagina.  When  the  vaginal  wall  is  fully  lifted, 
these  muscles  may  be  fully  exposed,  and  when  the  cor- 
responding surfaces  of  both  sides  are  well  brought 
together  the  brims  of  the  levators  must  be  sewn  to 
each  other.  I  do  not  doubt  that  in  Hegar's,  in  a  high 
Tait's  or  Fritsch's  operation,  as  in  all  others  in  which 
the  vagina  is  posteriorly  extensively  denuded,  the 
narrowing  of  the  levatoric  slit  by  these  processes  is 
the  main  part  of  the  permanent  success." 

In  1900,  Ziegenspeck  first  recorded  the  direct 
suture  of  the  levator  ani  in  perineorrhaphy  on  the 
living,  while  Duval  and  Proust  published  an  elabor- 
ately illustrated  monograph  on  "Levator  JNIyorrha- 
phy"  in  1902. 

These  early  publications,  which  practically  embody 


92  GYNECOPLASTIC   TECHNOLOGY. 

the  origin  and  principles  of  all  subsequent  levator 
operations,  instigated  a  flood  of  technical  propositions 
and  academic  controversy  which  to  the  present  time 
display  a  striking  diversity  in  conceptions  of  the 
anatomy,  topography,  and  dynamics  of  the  levator 
ani  muscle. 


CHAPTER  X. 

The  Mechanism  of  Intrapelvic  A'isceral 
Support. 

The  keynote  in  the  clinical  significance  and  surg- 
ical indications  of  perineal  lacerations  is  the  loss  of 
gynecic  support,  and  the  study  of  its  problems  must 
be  centered  in  the  myodynamics  of  the  pelvic  floor 
and  its  function  in  the  control  of  intra-abdominal 
pressure. 

Studies  of  normal  visceral  support  have  been  con- 
fined laro-elv  to  the  limits  of  anatomical  detail. 
Anatomy,  however,  has  not  fully  revealed  the  true 
mechanism  of  this  support.  It  is  a  gross  miscon- 
ception of  function  that  attributes  visceral  support  to 
the  textural  strength  of  ligaments  or  muscles.  The 
ligament  or  muscle  does  not  exist  that  can  perman- 
ently withstand  the  continuous  force  of  intra-abdom- 
inal pressure. 

The  muscular  and  ligamentous  elements  serve  to 
support  the  pelvic  contents,  not  by  virtue  of  their 
textural  resistance  to  displacement,  but  by  deflecthig 
the  displacing  force  of  intra-abdominal  pressure. 

Moreover,  the  perineal  musculature  should  not  be 
conceived  as  a  diaphragm,  passively  bearing  the 
weight  of  its  superposed  organs,  with  a  sphinctre 
action  at  the  pelvic  outlet.  It  is  an  active  integral 
part  in  a  complicated  deflecting  mechanism  that  dom- 
inates the  topographic  stability  of  all  the  abdominal 
viscera. 

(93) 


94 


GYNECOPLASTIC   TECHxNOLOGY. 


The  influence  of  pressure  and  its  deflection  find 
familiar  exemplification  in  the  mechanism  of  labor 
when  the  initial  direction  of  the  expulsive  force  be- 
comes deflected  by  the  pelvic  planes,  and  thus  impels 
the  fetal  ovoid  through  the  different  axes  of  the 
parturient  canal. 


Fig.  40. — Normal  nulliparous  vulva 


The  radical  cure  of  inguinal  hernia  became  possi- 
ble only  with  the  realization  of  its  two  essentials, 
namely,  the  apposition  of  contractile  muscular  resist- 
ance to  the  hernial  area,  and  the  obliteration  of  its 
peritoneal  funnel.  In  other  words,  the  muscular  and 
serous  planes  are  so  reconstructed  as  to  re-establish 
the  normal  deflection  of  intra-abdominal  pressure, 
thus  causing  the  intestine  to  glide  oz'er  instead  of  into 
the  hernial  gap. 


MECHAXISM  OF  LXTRAPELVJC  SUPPORT. 


95 


In  inguinal  herniotomy,  the  freely  mobilized  con- 
joined tendon  with  its  contiguous  muscles  is  deliber- 
ately displaced  by  suture  to  Poupart's  ligament;  and 
yet  the  analogous  interposition  of  the  mobilized  leva- 
tor, essential  to  a  successful  perineorrhaphy  "(which 
is  practicall}'  a  vaginal  herniotomy),  is  stigmatized 
as  "unanatomic." 


Fig.  41. — Xormal  parous  vulva.     Competent  levator  ani  muscle. 

The  really  valid  objections  to  some  of  the  levator 
myorrhaphies  in  vogue — namely,  the  isolation  of  the 
muscle  ''through  a  slit  in  its  fascial  covering,"  "in- 
juries to  the  rectovaginal  plexus,  with  possible  throm- 
botic sequela  in  residual  dead  spaces" — are  inapplic- 
able to  a  technique  which  circumvents  these  deleteri- 
ous features  by  approaching  the  levator  bed  bluntly 
along  a  direct  plane  of  cleavage  existing  normally  be- 
tween the  vae'inal  mucosa  and  the  levator  fascia. 


96 


GYNECOPLASTIC   TECHNOLOGY. 


The  evolution  of  levator  myorrhaphy,  like  that  of 
every  other  surgical  procedure,  has  afforded  a  fer- 
tile field  for  attempts  at  originality  and  modification, 
some  of  which,  losing  sight  of  fundamental  principles, 
necessarily  defeat  their  own  ulterior  purpose. 

It  is  a  significant  fact  that  the  most  pernicious  of 
these  ''simplified"  methods  emanated  from  the  ranks 


Fig.  42. — Parous  vulva,  gaping  from  incompetent 
lacerated  levator  ani  muscle. 


of  the  general  surgeons.  To  "plunge  a  scissors" 
blindly  through  the  perineal  tissues,  "tease  out  a  few 
levator  fibres  on  each  side  and  sew  them  together," 
all  "done  within  five  to  six  minutes,"  is  levator  myor- 
rhaphy in  name  only,  and  nothing  more. 

No  corrective  procedure  in  all  gynecology  exacts 
a    more    intimate    regional    knowledsre    and 


greater 


MECHANISM  OF  INTRAPELVIC  SUPPORT.  97 

technical  skill  than  a  properly  executed  sutural  re- 
adjustment of  the  levator  ani  in  perineorrhaphy. 

The  morbidity  of  a  ])erineal  injury  manifests 
itself  by  palpable  evidences  of  impaired  support  at 
the  pelvic  outlet.  Every  perineal  laceration  that  im- 
pairs a  previously  normal  intrapelvic  support  has 
partly  or  completely  severed  the  junction  of  the  an- 
terior levator  segments  on  one  or  both  sides  of  the 
median  raphe;  the  resultant  "relaxed  vaginal  outlet," 
the  "colpocele,"  "rectocele,"  "cystocele,"  and  "decen-  v^ 
sus  uteri,"  present  only  different  degrees  and  succes- 
sive stages  in  the  ultimate  development  of  a  complete 
prolapse,  each  stage  being  proportionate  to  the  extent 
and  duration  of  the  muscular  lesion  in  the  pelvic 
floor. 

The  restoration  of  the  impaired  visceral  stability 
within  the  pelvis  demands  a  readjustment  of  balance 
between  an  expulsive  force  and  its  counteracting  re- 
tentive elements — that  is,  between  intra-abdominal 
pressure  and  its  deflecting  mechanism.  Paradoxical 
as  it  may  appear,  both  maintenance  and  disturbance 
of  visceral  equilibrium  are  the  resultants  of  one  and 
the  same  force,  namely,  intra-abdominal  pressure 
under  the  influence  of  its  balanced  or  unbalanced 
deflection. 

The  conditions  causing  and  modifying  intratho- 
racic pressures  have  been  the  subject  of  exact  re- 
search, and  the  conclusions  offered  meet  general 
acceptance.  This  is  not  the  case  with  intra-ahdoininal 
pressure. 

In  the  general  and  special  literature,  the  subject 
is  treated  under  discussions  of  splanchnoptosis,  ascites, 
and  circulatory  conditions.    ]\Iost  of  the  textbooks  on 


98  GYNECOPLASTIC   TECHNOLOGY, 

physiology  omit  the  topic  entirely,  while  the  standard 
works  on  Obstetrics,  Gynecology,  and  Surgery  allude 
to  intra-abdominal  pressure  so  sparsely  and  inaccur- 
ately that  very  little  is  to  be  gleaned  from  them. 

Martin  (1885),  in  discussing  the  causes  of  uterine 
displacement,  states  that  intra-abdominal  pressure  is 
the  essential  factor,  and  that  failure  of  the  pelvic 
floor  induces  a  diminution  of  this  pressure  and  a 
descent  of  the  uterus. 

Hegar  (1886)  asserts  that  the  pelvic  viscera  are 
dislocated,  not  only  by  relaxed  ligaments,  but  by 
diminution  of  intra-abdominal  pressure. 

The  fallacy  of  these  interpretations  becomes  ap- 
parent when  it  is  recalled  that  the  abdominal  and 
pelvic  cavities  present  one  continuous  chamber,  and 
that  pressure  recorded  at  any  one  point  within  this 
chamber  is  equivalent  to  the  pressure  at  the  same 
moment  at  any  other  point  in  the  chamber;  conse- 
quently, if  diminution  of  pressure  as  such  induced  a 
descent  of  the  pelvic  organs,  it  should  constitute  part 
of  a  synchronous  descent  of  all  superposed  abdominal 
organs,  which  is  contrary  to  clinical  experience. 

Much  of  this  confusion  is  due  to  the  misapplica- 
tion of  hydrostatic  principles  to  intraperitoneal  con- 
ditions. These  principles,  when  applied  to  homo- 
geneous fluids  under  pressure  in  a  retainer  of  uniform 
outline  and  resistance,  permit  of  exact  observations 
and  calculation;  but  the  abdominal  cavity  is  neither 
uniform  in  outline  nor  resistance;  its  walls  are  bony 
here  and  muscular  there,  while  its  contents  are  not 
homogeneous,  but  solid,  semisolid,  fluid,  and  gaseous. 

To  quote  further  from  a  few  of  the  more  extensive 
treatises  on  physiology : 


MECHANISM  OF  INTRAPELVIC  SUPPORT.  99 

Du  Bois-Reymond  (190S)  merely  states  that  there 
is  a  variation  in  intra-abdominal  pressure  due  to  the 
action  of  the  diaphragm. 

Hall  ( 1900J  considers  intra-abdominal  pressure 
at  zero  when  the  abdominal  muscles  are  at  rest,  but 
illustrates  the  rise  above  that  on  descent  of  dia- 
phragm and  contraction  of  the  abdominal  muscles. 
Although  his  tracings  are  probably  correct,  he  gives 
neither  base-line  nor  statement  as  to  what  fluid  he 
used  in  his  manometers  to  obtain  the  pressure  records. 
He  notes  the  effect  of  abdominal  pressure  on  venous 
and  lymphatic  flow. 

Landois  (1900)  refers  to  Hamburger's  work  of 
1 895- 1 896,  and  makes  the  curious  statement  that  ex- 
piration causes  a  rise  in  intra-abdominal  pressure  in 
man  and  dogs,  but  that  inspiration  has  this  eft'ect  in 
guinea  pigs.  A  slight  increase  in  abdominal  pressure 
causes  increased  heart  action  and  arterial  pressure, 
but  excessive  pressure  in  the  abdomen  decreases  both. 

Luciani  describes  the  use  of  rectal  and  esophageal 
bougies,  and  gives  tracings  of  intrathoracic  and  in- 
tra-abdominal pressures,  but  no  figures  as  to  the  facts 
observed  in  etherized  dogs.  The  essential  fallacy  of 
testing  such  pressures  through  a  contractile  hollow 
organ  he  does  not  observe.  He  finds  that  the  abdomi- 
nal pressure  varies  with  the  descent  of  the  diaphragm 
and  contraction  of  the  abdominal  walls. 

Schaefer  (1900),  after  noting  the  efifect  of  ab- 
dominal conditions  on  the  circulation,  points  out  the 
very  important  fact  that  the  tone  of  the  abdominal 
w^all  muscles  is  maintained  by  the  respiratory  centre. 
The  abdominal  pressure  as  maintained  by  the  ab- 
dominal walls  is  of  the  utmost  importance,  as  it  tonic- 


100  GYNECOPLASTIC   TECHNOLOGY. 

ally  maintains  the  calibre  of  the  great  veins,  and  can 
compress  them  or  allow  them  to  expand. 

Tigerstedt  (1906):  "By  abdominal  pressure  we 
mean  the  pressure  on  abdominal  viscera  produced  by 
the  simultaneous  contraction  of  the  diaphragm  and 
'the  abdominal  muscles."  He  gives  no  figures  or  trac- 
ings, and  considers  the  pressure  of  importance  only 
in  relation  to  defecation  and  in  labor. 

Briefly  stated,  intra-abdominal  pressure — or,  more 
specifically,  intraperitoneal  pressure — is  the  result- 
ant of  several  components,  the  most  potent  of  which 
are  muscular  contractions,  gravity,  intravisceral  ten- 
sion, and  atmospheric  pressure. 

Intraperitoneal  pressure,  while  continuous  in  ef- 
fect, varies  in  intensity  with  the  necessarily  diverse 
activity  of  its  muscular  component. 

For  practical  purposes,  these  pressure  variations 
may  be  defined  as  presenting  a  passive  and  an  active 
phase. 

The  passive  phase  is  the  state  of  normally  bal- 
anced minimum  intraperitoneal  tension  which  prevails 
under  the  ordinary  conditions  of  functional  activity. 
This  phase  is  of  physiologic  interest  only. 

The  active  phase  is  a  superinduced  condition  of 
hypertension,  resulting  from  augmented  eflr'orts  that 
incite  the  abdominal  and  thoracic  muscles  to  sudden 
or  sustained  maximum  contractions,  as  coughing, 
sneezing,  straining,  lifting,  etc.  It  is  this  phase  of 
pressure  which  tends  to  extrude  the  pelvic  viscera  in 
the  direction  of  least  resistance. 

When  a  perineal  laceration  involves  the  sphinctre 
ani,  prolapse  rarely  ensues,  because  ever}^  sudden 
augmentation  of  pressure  in  this  condition  is  promptly 


MECHANISM  OF  INTRAPELVJC  SUPPORT.  101 

reduced  by  the  involuntary  emptying  of  the  lower 
bowel  contents  through  the  gaping  anal  orifice  before 
the  increased  tension  can  exercise  its  displacing  force 
upon  the  pelvic  viscera. 

It  is  a  fundamental  law  in  dynamics  that  the 
direction  of  a  given  force  or  body  impelled  by  such 
force,  impinging  against  a  resistant  plane,  becomes 
deflected  in  a  fixed  and  definite  direction,  the  degree 
of  deflection  being  governed  by  the  angle  of  the  re- 
sisting or  deflecting  plane. 

The  same  law  is  dominant  in  establishing  and 
maintaining  visceral  equilibrium  against  the  displac- 
ing force  of  gravity  and  intra-abdominal  pressure. 
But  for  the  influence  of  deflecting  planes,  every  erect 
female  would  prolapse  her  abdominal  contents  into 
the  pelvis  and  out  through  the  vagina.  As  the  result 
of  normal  deflection,  a  pressure  of  80  mm.  in  the 
abdominal  cavity  is  reduced  to  60  mm.  at  the  cervix, 
40  mm.  in  the  vagina,  and  20  mm.  at  the  introitus 
(G.  H.  Noble),  thus  resembling  a  placid  pool  along 
the  edge  of  a  rapid  vortex. 

The  entire  abdominal  cavity  constitutes  a  com- 
pound deflecting  chamber  presenting  multiple  planes, 
some  fixed  and  others  mobile,  that  deflect  pressure  at 
various  and  varying  angles  to  each  other. 

In  the  pelvis,  the  fixed  or  bony  planes  may  be 
designated  expulsive  planes,  inasmuch  as  they  tend  to 
deflect  the  direction  of  pressure  into  line  with  the 
axis  of  the  pelvic  outlet.  They  are  practically  iden- 
tical with  the  established  obstetric  planes,  among 
which,  however,  the  sacral  hollow  is  the  most  potent, 
as  exemplified  in  its  dominance  on  the  final  course  of 


102 


GYNECOPLASTIC   TECHNOLOGY. 


the  fetal  head;  any  viscus  that  falls  into  the  line  of 
this  expulsive  plane  must  eventually  prolapse. 

In  the  same  sense,  the  mobile  planes  are  retentive 
planes,  in  so  far  as  they  deflect  or  disperse  pressure 


Fig.  43. — In  an  abdominal  cavity  of  normal  skeletal  configura- 
tion a  true  vertical  in  contact  with  the  sacrolumbar  angulation  will 
impinge  against  the  inner  face  of  the  symphysis  pubis  at  its  lower 
border.  This  vertical  represents  the  initial  direction  of  intra- 
abdominal pressure  at  the  pelvis  brim. 

in  directions  that  tend  to  preserve  the  topographic 
stability  of  the  pelvic  contents.  These  are  presented 
by  the  mobile  uterus,  with  its  broad  ligament  exten- 
sions, and  the  levator  ani  in  the  pelvic  floor. 


MECHANISM  OF  JNTRAPELVIC  SUPPORT.  1(33 

In  an  al^dominal  cavity  of  normal  skeletal  config- 
uration, a  true  vertical,  in  contact  with  the  centre  of 
the  sacrovertebral  promontory,  will  impinge  against 
the  inner  face  of  the  symphysis  pubes  at  its  lower 
border.  The  sacrovertebral  promontory  is  situated 
y/2  inches  above  the  symphysis,  so  that  the  vertical 
line  which  represents  the  initial  direction  of  intra- 
abdominal pressure  at  the  pelvic  brim  passes  over, 
and  not  into,  the  pelvic  cavity. 

In  other  words,  the  posterior  abdominal  wall  ter- 
minating at  the  sacrovertebral  angle  is  3^  inches 
shorter  than  the  anterior,  which  ends  at  the  symphy- 
sis pubes.  Dynamically  the  pelvic  cavity  thus  pre- 
sents a  separate  communicating  chamber  or  elbow, 
hollowed  out  of  the  posterior  abdominal  wall,  with 
the  sacrum  as  an  inclined  roof,  from  which  the 
uterus  is  suspended  by  its  sacro-uterine  ligaments. 

Accordingly,  under  ordinary  conditions,  the  di- 
rection of  intra-abdominal  pressure  within  the  pelvis 
is  such  as  to  fall  upon  the  posterior  surface  of  the 
uterus  and  broad  ligaments.  In  deflecting  the  direc- 
tion of  this  pressure  to  maintain  its  equilibrium,  the 
normally  anteverted  uterus  may  be  compared  to  a 
lever  of  unequal  arms,  poised  over  a  fulcrum  pre- 
sented by  the  intravaginal  crest  of  the  perineum. 
This  intravaginal  crest  is  formed  by  the  junction  of 
the  pubococcygeal  levator  segments  to  the  median 
raphe. 

The  longer  fundal  arm  of  the  uterine  lever,  which 
rests  upon  the  subjacent  bladder  and  pubic  surface, 
is  movable  upwards,  extreme  movement  in  this  direc- 
tion being  limited  by  the  round  ligaments,  which,  up 
to  a  certain  point,  prevent  tilting  of  the  uterus  into 


104  GYNECOPLASTIC   TECHNOLOGY. 

the  axis  of  the  sacral  expulsive  plane.  The  shorter 
cervical  arm  of  the  uterine  lever  projects  free  into 
the  vaginal  fornix. 

By  this  adjustment  intra-abdominal  pressure  at 
first  tends  to  depress  the  normal  level  of  the  uterine 
plane  as  a  whole,  until  its  anterior  pole  is  arrested 
by  the  resistance  of  the  subjacent  bladder  and  upper 
pubic  surface;  augmentation  of  the  pressure  at  this 
stage  acts  upon  the  free  posterior  cervical  pole,  forc- 
ing it  upon  its  perineal  fulcrum. 

Were  this  pressure  to  continue  undeflected,  the 
round  ligaments  would  yield,  and  the  progressive 
descent  of  the  cervical  pole,  with  its  corresponding 
elevation  of  the  fundus,  would  gradually  tilt  the 
uterus  into  retroversion.  In  this  position  it  sustains 
the  pressure  impact  upon  its  anterior  instead  of  its 
posterior  surface,  and  is  thus  crowded  into  line  with 
the  axis  of  the  vaginal  outlet.  Under  normal  con- 
ditions, it  is  this  last  phase  of  the  pressure  that  is 
counteracted  by  the  deflecting  function  of  the  levator 
ani  muscle. 

The  stimulus  which  incites  the  abdominal  mus- 
culature into  activity,  and  thereby  augments  intra- 
abdominal pressure,  induces  a  simultaneous  contrac- 
tion in  the  levator  ani. 

The  elements  of  this  muscle  are  so  arranged  that 
their  contraction  elevates  the  level  and  the  angle  of 
the  pelvic  floor.  This  elevation  lifts  the  intravaginal 
crest  or  fulcrum  up  to  the  uterine  lever,  raises  the 
depressed  cervical  pole  of  the  lever  to  the  level  of  its 
fundal  pole,  thus  restoring  anteversion;  at  the  same 
time,  the  elevation  of  the  perineal  plane  narrows  the 
essential  uterovaginal   angle,   preserves   the  potenti- 


MECHANISM  OF  INTRAPELVIC  SUPPORT.  105 

ality  of  the  vagina  by  converting  its  actual  canal  into 
a  valvular  slit,  and  mechanically  closes  the  pelvic 
outlet. 

Every  augmentation  of  pressure  demands  a  pro- 
portionate increase  in  resistance,  which  demand  is 
promptly  met  by  a  synchronous  countercontraction 
of  the  levator  ani. 

Accepting  the  principle  of  deflection  as  funda- 
mentally applicable  to  the  problem  of  visceral  support, 
it  follows  as  a  natural  corollary  that  every  deviation 
from  the  normal,  in  the  angle  and  resistance  of  the 
perineal  deflecting  plane,  must  necessarily  induce  a 
corresponding  deviation  in  the  direction  of  intra- 
abdominal pressure,  with  resulting  topographic 
disturbance. 

The  normal  contours  and  topographic  arrange- 
ment of  the  pelvic  floor  and  its  superimposed  organs 
all  conform  to  subserve  this  deflecting  function. 

A  sagittal  section  of  the  pelvic  floor,  wath  the  body 
in  the  erect  posture,  shows  the  cutaneous  perineum 
extending  horizontally  from  the  posterior  vulvar  com- 
missure to  the  coccyx,  while  the  upper  or  intra- 
abdominal surface,  conformable  with  its  function  as 
a  deflecting  plane,  slopes  obliquely  from  the  pubes, 
downward  and  backward,  in  a  line  parallel  to  the  axis 
of  the  pelvic  inlet. 

This  divergence  of  the  upper  from  the  under  sur- 
face outlines  the  triangular  configuration  of  the  pelvic 
floor.  Its  apex  at  the  coccyx  is  less  than  half  an  inch 
in  thickness ;  its  base  at  the  pubic  arch  occupies  a 
space  of  over  3  inches. 

The  vagina,  bladder,  uterus,  and  rectum  rest  upon 
and  constitute  part  of  this  inclined  plane,  the  whole 


106  GYNECOPLASTIC   TECHNOLOGY. 

Structure  being  swung  in  the  muscular  hammock 
formed  by  the  levator  ani  loops,  which,  by  their  con- 
tractile response  to  pressure,  maintain  its  form,  level, 
incline,  and  topographic  relations. 

Contrary  to  general  impression,  the  direction  of 
the  vaginal  canal  is  practically  horizontal.    It  is  inter- 


Fig.  44. — Diagrammatic  scheme  of  normal  pressure  deflection  by  the 
intrapelvic  planes,  and  the  direction  of  levator  contraction. 

posed  between  the  muscular  layer  in  the  pelvic  floor 
and  the  superimposed  pelvic  viscera,  the  disposition  of 
its  walls  being  superior  and  inferior,  not  anterior  and 
posterior. 

Its  orifice  is  held  in  the  most  anterior  of  the  leva- 
tor loops  (pubo-coccygens),  in  a  plane  just  posterior 
to  that  of  the  pubic  arch. 


MECHANISM  OF  INTRAPELVIC  SUPPORT.  107 

Normally,  the  uterus  lies  nearly  parallel  to  the 
puborectal  segment  of  the  levator  ani,  which,  on  con- 
tracting, draws  the  perineum  forward  and  beneath 
the  bladder,  thus  covering  the  outlet  like  a  sliding 
floor. 

Every  augmentation  of  pressure  that  forces  the 
uterus  downward  stimulates  the  levator  to  lift  the 
vagina  upward,  constricting  its  orifice  against  the 
pubic  arch  and  closing  the  uterovaginal  angle;  the 
greater  the  pressure,  the  narrower  the  angle  and  the 
firmer  the  resulting  vaginal  closure. 

Concisely  stated,  the  levator  ani  diminishes  the 
force  of  intra-abdominal  pressure  upon  the  pelvic 
contents  by  deflecting  the  direction  of  that  pressure, 
augments  the  resistance  to  the  pressure  by  closing  the 
uterovaginal  angle,  and  obstructs  the  pelvic  outlet 
against  the  pressure  by  compressing  the  vaginal 
canal. 

It  is  the  tensor  of  the  pelvic  fascia,  the  antagonist 
of  the  diaphragm  and  abdominal  muscles,  contract- 
ing when  these  opposing  muscles  contract,  and  re- 
laxing when  they  relax. 

When  intact,  it  maintains  the  equilibrium  of  the 
pelvic  organs ;  when  its  integrity  is  impaired,  equilib- 
rium is  disturbed  and  displacement  ensues.  Finally, 
in  disorders  of  the  lower  spinal  segments,  especially 
in  Spina  hiiida  and  Spina  hiUda  occulta,  involving 
the  fourth  sacral  nerves,  prolapse  ensues  as  the  result 
of  levator  paralysis,  and  this  notwithstanding  that 
the  ligaments  and  fascia  are  intact. 

Such  is  the  function  of  the  perineum,  and  such 
the  measure  of  its  importance  as  a  visceral  support. 
It  follows  that  the  gravity  of  perineal  lacerations  is 


108  GYNECOPLASTIC   TECHNOLOGY. 

proportionate  to  the  resulting  impairment  of  its  mus- 
cular element,  such  impairment  inducing  a  tendency 
to  prolapse,  not  because  any  direct  support  to  the 
viscera  is  severed,  but  because  the  equilibrium  of  in- 
trapelvic  pressure  is  deranged  and  its  expulsive  force 
undeUected. 


CHAPTER  XI. 

The  Levator  Ani  Muscle. 

In  1889  Robert  L.  Dickinson  wrote:  'T  venture 
to  affirm  that  there  is  no  considerable  muscle  in  the 
body  whose  form  and  function  are  more  difficult  to 
understand  than  those  of  the  levator  ani,  and  about 
which  such  nebulous  impressions  prevail.  The  draw- 
ings of  it  are  complicated,  the  impressions  of  its 
strength  and  importance  are  conflicting,  and  the 
knowledge  concerning  it  is  fragmentary  and  not 
readil}^  accessible.  .  .  .  One  commonly  meets  with 
the  idea  that  the  levator  is  a  kind  of  muscular  funnel 
tapering  to  the  anus,  and  serving  to  pull  it  directly 
upward  after  defecation.  This  is  absolutely  tmtrue. 
The  muscle  rather  resembles  a  horseshoe — a  sling 
attached  to  the  pubes  in  front,  its  sweep  reacting 
horizontally  backward,  to  circle  like  a  collar  the 
rectum  and  vagina.  Its  action  in  woman  is  to  drag 
the  lower  ends  of  the  vagina  and  rectum  forward, 
level  to  the  symphysis." 

This  statement  in  its  entirety  holds  good  at  the 
present  time. 

The  levator  ani  is  not  a  single  muscle,  but  a 
radially  disposed  plexus  of  flat  muscle  segments,  en- 
closed and  separated  by  fascial  investments,  and  com- 
posed of  striped  and  unstriped  muscle-fibres.  AA'hile 
its  individual  segments  may  be  separately  demon- 
strated at  their  origin,  they  become  intimately  and 
inseparably  blended   with   each   other   and  with   the 

(109) 


no  GYXECOPLASTIC   TECHNOLOGY. 

aponeurotic  tissues  in  the  perineal  centre  and  ano- 
coccygeal raphe. 

Functionall}^,  a  sharp  demarcation  characterizes 
the  coccygeal  and  pubic  divisions  of  the  levator 
muscle. 

The  coccygeal  division  comprises  the  thin  pos- 
terior semi-membranous  segments  that  are  inserted 


Fig.  45. — The  levator  ani  seen  from  below.  The  cut  ends 
projecting  upward  are  those  fibres  which  run  into  the  recto- 
vaginal septum.     (Dickinson.) 

into  the  sides  and  tip  of  the  coccyx.  These  are  de- 
void of  special  function,  representing  vestigial  struc- 
tures, homologous  with  the  caudal  flexors  in  the 
lower  animals,  and  are  of  anthropologic  interest 
only. 

The  functionall}'  essential  elements  of  the  levator 
ani  are  the  pubic  bands  commonly  designated  "pubo- 
vaginalis,"  "puborectalis,"  or  "pubococcygeus." 

The  bulk  and  strength  of  these  muscles  are  much 


THE  LEVATOR  AXI  MUSCLE. 


Ill 


greater  than  current  anatomic  descriptions  and  post- 
vwrtcni  appearances  would  indicate. 

Their  hnes  of  origfin  extend  for  i  and  ilA  inches 
on  either  side  of  the  posterior  surface  of  the  pubic 
symphysis,  thus  equalhng  in  width  the  average  ster- 
nomastoid :  they  are  twice  as  thick  as  the  diaphragm, 


Fig.  4o. — Origin  of  the  left  anterior  (pubococc3-geal)  loop  of 
the  levator  ani  from  the  posterior  symphyseal  surface  (the  right 
loop  removed).  S,  Symphysis.  U,  Urethra.  V,  Vagina.  P,  Peri- 
neum. 1,  Pubovesical  ligament;  2,  Origin  of  pubococcygeus ;  3, 
Iliococcygeus ;  4,  Internal  pudic  vessels ;  5,  Urethral  plexus ;  6, 
Upper  (inner)  surface  of  the  pelvic  diaphragm;  7,  Pubococcygeal 
loops  of  the  levator  ani  muscle. 


weigh  one-fourth  as  much  as  the  external  oblique, 
altogether  presenting  a  muscular  support  exceeding 
that  guarding  the  inguinal  ring. 

Their  dynamic  energy,  as  developed  by  Dickin- 


112  GYNECOPLASTIC    TECHNOLOGY. 

son's   experiments,   ranges   from    lo  to  27   traction 
pounds. 

These  pubic  segments  course  almost  horizontally 
backward  and  inward  along  the  lateral  vaginal  walls. 


.     Fig.  47. — The  intrapelvic  line  of  origin  of 
the  levator  ani.     (Haynes.) 

They  converge  rapidly  toward  each  other  to  be- 
come inserted  into  the  rectovaginal  septum,  the 
perineal  centre,  the  rectal  walls  and  the  anococcygeal 
tendon,  encircling  the  vagina  and  rectum  in  distinct 
loops. 


THE  LEVATOR  ANI  MUSCLE.  113 

Their  median  borders,  which  are  plainly  palpable 
through  the  lateral  vaginal  walls,  a  half-inch  or  less 
behind  the  plane  of  the  hymen,  form  a  V-shaped  in- 
terspace which  embraces  the  introitus  under  the  pubic 
arch,  and  is  termed  the  levator  cleft. 


Fig.  48. — Levator  ani  fibres  normally  present  in  the 
rectovaginal  septum. 

A  study  of  the  vaginal  extrusions  resulting  from 
perineal  lacerations  reveal  elements  closely  analog- 
ous to  those  of  inguinal  hernia. 

Both  conditions  result  from  muscular  insufficiency 
over  a  vulnerable  intra-abdominal  site,  tunnelling 
their  outward  course  along  potential  channels  be- 
tween the  muscular  and  fascial  layers  of  the  abdom- 
inal walls. 


114  GYNECOPLASTIC   TECHNOLOGY. 

The  levator  ani  embracing  the  abdominal  floor  is 
as  much  an  abdominal  muscle  as  the  obliquus,  trans- 
versalis,  or  rectus.  Furthermore,  the  form  and 
nature  of  the  muscular  arrangement  guarding  the 
inguinal  openings  above  the  pubes  is  the  exact 
counterpart  of  the  levator  arrangement  beneath  the 
pubes. 

The  lacerated  levator  shanks  retract  upward  and 
outward  behind  the  pubic  rami  towards  their  para- 
symphyseal  origin,  widening  the  introitus,  with  re- 
sulting eversion  and  ultimate  protrusion  of  the  vagi- 
nal mucosa  through  the  gaping  orifice. 

The  cleft  created  by  the  separation  of  their  median 
borders  gives  vent  to  the  anterior  rectal  wall  in  the 
formation  of  rectocele. 

The  vaginal  floor,  thus  deprived  of  its  muscular 
crotch,  and  shortened  to  the  extent  of  its  laceration, 
exposes  the  upper  vaginal  wall  and  leaves  the  bladder 
base  unsupported. 

The  entire  vaginal  canal,  with  its  superimposed 
viscera,  descends  to  a  lower  level.  The  prolapsed 
vaginal  pouches,  with  their  hernial  contents,  gradu- 
ally drag  the  anteverted  cervix  toward  the  yielding 
outlet.  The  uterovaginal  angle  becomes  widened,  the 
uterus  telescopes  the  vagina,  and  the  prolapse  is 
complete. 


CHAPTER  XIT. 

The  Pelvic  Fascia. 

The  levator  ani,  like  all  skeletal  muscles,  is  in- 
vested with  fascial  sheaths  whose  relative  function 
in  the  mechanism  of  intrapelvic  support  presents  a 
topic  of  unsettled  controversy.  The  study  and  de- 
lineation of  this  fascia,  like  that  of  the  levator,  aside 
from  its  intrinsic  difficulties,  is  encumbered  by  a  di- 
versified terminology,  which  depicts  a  confusing  mul- 
tiplicity of  subdivided  layers. 

In  the  pelvis,  as  elsewhere,  the  muscular  domin- 
ance in  visceral  support,  direct  or  indirect,  accords 
with  the  established  morphological  law,  that  "all 
weight-bearing  function  is  essentially  muscular  in 
nature,  clonic  in  rhythm,  and  continuous  in  efifect." 

With  the  assumption  of  the  erect  attitude  by  man, 
the  pubic  levator  segments  developed  their  support- 
ing function,  while  the  coccygeal  or  caudal  segments 
degenerated  into  thin  membranous  expansions. 

In  the  biological  scale,  the  tailless  anthropoid  apes 
present  a  well  defined  levator  ani,  similar  in  form  and 
function  to  the  human  muscle. 

This  evolutional  transition  of  the  levator,  from 
caudal  flexor  to  perineal  contractor,  oflfers  a  key  to 
the  complicated  topographic  arrangement  of  the 
pelvic  fascia  along  the  following  lines : 

The  fibres  of  the  primitive  pubic  muscle-bundles 
(pubo-coccygens),  proliferated  around  the  pre-exist- 
ing vaginal  and  anal  canals,  between  the  lavers  of 

(115) 


(116J 


THE  PELVIC  EASCIA. 


117 


the  deep  pelvic  fascia,  which  thus  constituted  the 
levator  sheath ;  the  upper  layer  of  this  sheath  is 
known  as  the  ''rectovesical  fascia",  while  the  lower 
is  termed  "levator  fascia". 

Concisely  stated,  the  pelvic  fascia,  the  rectovesical 
fascia,  and  the  levator  fascia,  like  the  iliac  and  ob- 
turator  fascia,   are  all   in   reality  but   one   stratified 


^  Antfpu6ic  ^t'^^^ 


u»crMffj^ 


Fig.  50. — The  pelvic  outlet. 

sheath,  practically  continuous  with  the  transversalis 
fascia,  thus  lining  the  abdominal  muscles  above  and 
enveloping  the  levator  muscles  below.  The  rectoves- 
ical and  levator  fasciae  fuse  in  the  levator  cleft. 

Topographically  it  is  essential  to  note: — 

That  the  origin  of  the  levator  ani  and  its  fascial 
sheath  are  on  a  level  with  the  internal  or  upper  sur- 
face of  the  pubic  arch. 


^    ^cref 


^  2 


^/^p^ 

.  \ 

u  \ 

"i 

\^ 

X 

\ 

1^ 

if 

8^ 

bo 


(118) 


(iiyj 


(120) 


(121) 


122  GYNECOPLASTIC   TECHNOLOGY. 

The  pelvic  outlet  in  the  lithotomy  position  is 
lozenge-shaped,  consisting  of  two  triangles,  base  to 
base.  The  apex  of  the  anterior  triangle  is  at  the 
symphysis ;  that  of  the  posterior  at  the  sacrococcygeal 
joint. 

The  anterior  triangle  presents  the  vaginal  and 
urethral  openings;  the  posterior  triangle  presents  the 
anus. 

The  common  base-line  between  the  two  extends 
just  anterior  to  the  ischial  tuberosities,  correspond- 
ing to  the  direction  and  position  of  the  deep  trans- 
versus  perinei  muscle. 

The  surgical  path  in  the  pelvic  floor  from  the 
vulvar  outlet  to  the  ■  levator  fascia  traverses  two 
thin,  indistinct  fascial  planes — first,  the  "superficial 
perineal  fascia,"  composed  of  two  layers  directly  con- 
tinuous with  the  general  subcutaneous  fascia,  con- 
taining a  layer  of  fat  only;  the  second  fascial  plane 
is  attached  to  the  anterior  or  lower  surface  of  the 
pubic  arch;  it  envelops  the  "superficial  transversus 
perinei,"  the  "bulbo-cavernosus ;"  the  "btilbus  vesti- 
buli,"  and  the  "bartholinian  glands." 

The  deep  transversus  perinei  occupies  the  cleft 
between  this  second  plane  and  the  levator  fascia. 

These  lower  fascial  planes  and  their  muscles  are 
isolated  with  difficulty  in  the  cadaver,  as  they  are  in- 
timately blended  along  their  lines  of  contact,  while 
in  the  living  their  definition  is  blurred  by  cicatricial 
distortion  and  attenuation. 

Surgically,  they  are  of  secondary  importance. 
The  two  transversus  perinei  are  at  best  very  weak 
subordinate  adjuvants  in  intrapelvic  support,  while 


THE  PELVIC  FASCIA.  123 

the  "bulbo-cavernosus,"  sometimes  misnamed  "sphinc- 
tre  vagiiice"  or  "constrictor  cimi,"  simply  controls 
the  turgescence  of  the  erectile  tissue  in  the  vulva 
and  clitoris,  exercising"  no  supporting  function  what- 
soever. 


CHAPTER  XIII. 

Levator  jMyorrhaphy. 

The  musculofascial  elements  located  in  the  leva- 
tor plane,  constitute  the  surgical  objective  point  in 
perineorrhaphy. 

Before  denuding  the  seat  of  lesion  it  is  essential 
to  locate  the  two  levator  shanks,  each  being  distinctly 
palpable  through  the  lateral  vaginal  walls,  behind  the 
h3^menal  border,  where  they  converge  downward  to- 
ward the  perineal  centre,  and  may  be  followed  up- 
ward and  outward  to  their  parasymphyseal  origin 
on  the  posterior  plane  of  the  pubes. 

The  primary  laceration  separates  the  tissues  at 
the  levator  junction  on  one  or  the  other  side  of  the 
median  line,  with  subsequent  retraction  of  both  mus- 
cle shanks.  This  alters  their  normal  relation  to  each 
other  and  to  their  surroundings. 

Instead  of  forming  an  acute  angle,  with  its  apex 
fixed  in  the  perineal  centre,  they  run  nearly  parallel 
throughout  their  course. 

The  normal  intravaginal  perineal  crest  formed 
by  this  apex  of  the  two  muscle  shanks,  and  constitut- 
ing a  fulcrum  to  the  uterus,  is  obliterated,  while  the 
posterior  vaginal  wall  is  foreshortened. 

Contrary  to  general  impression,  the  torn  levator 
muscle  is  more  frequently  hypertrophied  than  atro- 
phied, especially  in  its  upper  portion,  owing  to  its 
augmented  compensatory  function,  due  to  its  mal- 
position. 

(124) 


LEVATOR    MYORRHAPHY. 


125 


Fig.  55. — Perineoplasty  (author's  method).  OutHning  incision 
on  the  vulvar  mucosa  from  corresponding  points  just  outside  the 
lateral  hymenal  edges  to  the  cicatricial  mucocutaneous  centre  of  the 
posterior  commissure. 


126 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  56. — Perineoplasty  (author's  method).  The  outHned  flap  is 
carefully  elevated  from  the  underlying  cicatricial  and  fascial  layer 
by  feather-edge  dissection  up  to  its  base,  as  the  thinnest  possible 
(almost  translucent)  flap  consisting  of  vaginal  mucosa  only. 


LEVATOR    MVORRIIAPHY. 


127 


Atrophy  of  either  nmscle  shank  occurs  only  as 
the  resuU  of  direct  destructive  traumatism  to  the 
muscle  belly  hy  crushing  with  obstetric  forceps. 

To  correctly  expose  the  seat  of  lesion  and  the 
levator  shanks,  it  is  necessary  to  recall  that  the  up- 
per and  under  fascial  sheaths  enclosing  the  levator 
ani — namelv,    the   rectovesical    and   levator   fascia — 


Fig.  57. — In  elevating  the  vaginal  mucosa,  the  flap  is  steadied 
by  the  left  hand,  the  index  finger  exercising  counter-pressure,  con- 
trolling the  course  and  progress  of  the  denudation. 


blend  in  the  median  triangTilar  space  between  the 
inner  muscle  borders  known  as  the  levator  cleft,  the 
contiguous  fascial  surfaces  being  held  in  apposition 
by  a  sparse  reticular  layer,  which  offers  a  natural 
line  of  cleavage  directly  to  the  muscle. 

The  essential  steps  in  the  operative  technique  that 
demand  detailed  elucidation  are: — 

L  Elevation  of  a  thin,  almost  translucent  trian- 
gular flap  of  mucosa  from  the  posterior  vaginal  wall. 


128 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  58. — The  flap  dissection  is  necessarily  sharp  through  the 
dense  cicatrized  area,  until  the  uninvolved  yielding  reticular  struc- 
ture at  the  lower  pole  of  the  rectovaginal  septum  is  reached,  whence 
it  is  continued  bluntly  on  either  side  of  the  centre  to  the  crest  of 
the  rectocele. 


X 

I — I 

X 

w 

< 


S 


«  2 

o  ~ 


So  cj 


»  o 


o  r. 

3 


LEVATOR   MYORRHAPHY. 


129 


TT.  Exposure  and  mobilization  of  the  puborectal 
levator  shanks. 

III.  Sutural  readjustment  of  the  muscle. 

IV.  Coaptation  of  the  vai^inal  Hap. 

V.  Closure  of  the  superficial  perineal  layers. 


Fig.  59. — Fascial  slits  for  levator  exposure,  necessitated 
by  improper  denudation. 

Preliminary  to  the  first  step,  any  concomitant 
displacement  of  the  uterus  or  bladder,  as  well  as 
pathological  condition  of  the  cervix,  must  be  cor- 
rected by  measures  which  will  be  considered  under 
their  respective  captions. 

9 


130 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  60. — Incorrect  method  of  exposing  the  levator  muscle 
by  slitting  the  fascia. 


LEVATOR    MYORRHAPHY.  131 

The  delineation  of  the  flap  is  faciHtated  by  hook- 
ing a  tenaculum  on  each  side  of  the  vaginal  orifice 
into  the  labia  majora,  and  a  third  into  the  centre  of 
the  posterior  mucocutaneous  margin. 

A  very  superficial  outlining  incision  is  carried  by 
light  strokes  of  the  knife  on  the  vulvar  mucosa  from 
corresponding  points  just  outside  the  lateral  hymenal 
edges  to  the  mucocutaneous  centre  of  the  posterior 
commissure.  This  constitutes  a  triangular  area,  with 
its  apex  and  base  just  the  reverse  to  that  of  Hegar. 

The  lowest  hymenal  caruncles  are  too  frequently 
situated  at  different  levels  to  be  standardized  as  fixed 
starting  points  in  all  cases. 

TJie  triangular  surface  thus  outlined  must  he 
carefully  elevated  from  all  underlying  tissues  by 
feather-edge  dissection  up  to  its  base  as  the  thinnest 
possible,  almost  translucent  Hap,  consisting  of  vaginal 
mucosa  only. 

The  flap  dissection  at  first  is  necessarily  a  sharp 
one,  through  the  dense  cicatrized  area  until  the  un- 
involved  yielding  reticular  tissue  in  the  lowest  pole 
of  the  rectovaginal  septum  is  reached,  when  it  may  be 
continued  bluntly  upward  to  the  natural  point  of  con- 
tact between  the  anterior  and  posterior  vaginal  wall, 
commonly  designated  as  the  "crest  of  the  rectocele." 

Owing  to  the  proximity  of  the  rectovaginal 
venous  plexus,  it  is  neither  advisable  nor  necessary 
to  continue  the  cleavage  of  the  tissues  upward  in  the 
median  line  above  this  point  of  the  rectovaginal 
septum  at  this  stage  of  the  procedure. 

If  a  sufficiently  thin  flap  of  mucosa  has  been  sepa- 
rated from  the  posterior  vaginal  wall,  at  the  correct 
anatomical  level,  the  exposed  submucous  surface  will 


132 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  61. — Perineoplasty  (author's  method).  Suture  traction  on 
the  retracted  upper  part  of  the  levator  ani,  and  blunt  mobilization 
of  its  left  shank  by  a  gauze-covered  finger. 


LEVATOR    MVORRIFAIMIY. 


133 


Fig.  62.— Perineoplasty   (author's  method).     The  levator  ani  partly 
exposed,  covered  by  a  thin  perimyseal  sheath. 


134 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  63. — Perineoplasty  (author's  method).  The  sutures  passed 
entirely  round  (not  through)  the  muscle-shanks,  encircling  them 
so  as  to  secure  the  broadest  possible  side-to-side  surface  contact 
under  the  vaginal  floor. 


LEVATOR    MYORRHAPHY.  135 

lead  directly  into  the  normal  line  of  cleavai^"e  between 
the  two  levator  sheaths,  where  the  finger  tip  may  be 
insinuated  and  pushed  gently  in  a  direction  outward 
and  upward,  on  each  side  of  the  median  line,  toward 
the  posterior  surface  of  the  pubic  rami,  and  expose 
the  muscle  near  its  origin. 

Here  it  is  necessary  to  observe  that  the  pull  on 
the  flap  during  its  elevation  imperceptibly  drags  the 
submucous  tissues  forward  in  a  manner  to  overlap 
the  essential  plane  of  cleavage  to  the  levator  ani. 
This  overlapping  tends  to  divert  the  further  course 
of  dissection  into  the  lower  fascial  and  cicatricial 
planes,  which  blurs  the  definition  of  the  muscle,  and 
necessitates  supplemental  fascial  incisions  for  its  ex- 
posure and  mobilization,  all  of  which  are  circum- 
vented by  frecjuently  releasing  the  pull  and  carefully 
grasping  and  clipping  all  attached  reticular  meshes 
with  mouse-tooth  forceps  and  scissors,  as  close  as 
possible  to  the  under  flap  surface. 

Barring  the  penetration  of  an  occasional  trau- 
matic varix  in  the  reticular  structure,  which  is  easily 
controlled  by  pressure,  and  a  small  spurting  branch 
of  the  internal  pudic  artery,  no  bleeding  of  import  is 
encountered  in  this  procedure. 

The  vaginal  Hap  is  not  excised. 

The  upper  pole  of  the  muscle,  exposed  by  the 
blunt  penetration,  with  the  finger  tip  between  the 
levator  and  rectovesical  fascia,  is  found  completely 
enveloped  in  a  hitherto  undescribed  thin,  smooth 
perimyseal  membrane,  which  for  convenience  may 
be  termed  the  surgical  sheath.  Neither  this  sheath 
nor  its  contiguous  fascial  coverings  should  be  per- 
forated during  any  step  in  the  operation.     At  times 


136 


GYNECOPLASTIC   TECHNOLOGY. 


?^  r'  ~^«^.'^;;#i^'^'i 


-.J  <*wi:*aH*»WMa«!;fr/> 


J5*^^ii^«^?ediss-* 


LeVu 


Fig.  64. — Perineoplasty  (author's  method).     Levator 
sutures  in  situ  and  tied. 


LEVATOR    MYORRHAPHY.  137 

the  digital  retraction  of  the  wound  edges  creates  deep 
fascial  folds  which  may  simulate  the  levator  shanks 
so  closely  as  to  confuse  the  operator.  This  is  averted 
by  palpating  the  exposed  muscle  to  its  posterior  pubic 
origin. 

The  identity  of  both  muscle  shanks  thus  estab- 
lished, their  outer  borders  should  be  mobilized  along 
their  entire  length  to  an  extent  permitting  of  their 
median  approximation  without  tension. 

The  method  practised  by  a  number  of  surgeons, 
in  which  a  thin  edge  of  muscle  is  drawn  through  a 
slit  in  the  lateral  fascia  on  each  side  and  sutured 
without  previous  mobilization,  is  not  to  be  com- 
mended, as  it  results  in  the  formation  of  a  thin  cre- 
scentic  diaphragm  behind  the  introitus,  productive  of 
disagreeable  sequellse. 

On  the  other  hand,  the  muscle  must  not  be  enu- 
cleated or  dislocated  from  its  normal  bed;  its  natural 
mobility  is  simply  amplified  by  gently  stretching  its 
connections  to  contiguous  structures. 

The  operative  field,  correctly  exposed  before 
suture,  should  present  a  denuded  irregular  triangle, 
with  its  base  line  at  the  junction  of  vaginal  flap  and 
rectovaginal  septum,  its  sides  the  inner  borders  of  the 
levator  shanks,  edged  by  the  furled  layer  of  the 
levator  fascia. 

From  three  to  four  interrupted,  forty-day  chromic 
gut  sutures  coapt  the  muscles  and  close  the  intermus- 
cular gap  in  front  of  the  rectocele.  Each  suture  is 
passed  from  side  to  side,  not  tJi rough  but  entirely 
around  both  muscles,  encircling  them  so  as  to  secure 
their  broadest  possible  surface  contact  under  the 
vaginal  floor. 


138 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  65. — Perineoplasty  (author's  method).  The  elevated  flap 
of  vaginal  mucosa  is  not  ablated.  Its  edges  are  sutured  from  its 
central  tip  downward  to  form  a  hollow  cone. 


LEVATOR    MYORRHAPHY, 


139 


Fig.  66. — Perineoplasty  (author's  method).  The  hollow  cone  of 
vaginal  mucosa  is  inverted  upon  itself,  tucked  into  the  vagina,  and 
snugly  applied  to  the  posterior  surface  of  reunited  levator  ani 
muscle. 


140 


GYNECOPLASTIC    TECHNOLOGY. 


The  rectocele  should  not  be  caught  in  the  suture 
nor  pinched  between  the  muscles,  the  uppermost 
suture  being  inserted  just  high  enough  to  normally 
appose  the  lower  to  the  upper  vaginal  wall  when  the 
flap  is  replaced. 


Fig.  67. — Perineoplasty  (author's  method).  Diagrammatic  sagit- 
tal section,  showing  the  inversion  and  application  of  the  inverted 
flap  of  vaginal  mucosa  to  the  posterior  surface  of  the  reunited 
levator  ani.  A,  Inverted  flap.  B,  Levator  ani.  C,  Superficial 
perineal  coverings. 


In  adjusting  the  superficial  coverings  no  vaginal 
mucosa  is  removed.  The  transverse  wound  is  con- 
verted into  a  perpendicular  slit  by  properly  applied 


LEVATOR    MYORKIIAIMIY.  141 

traction,  and  the  edges  united  side  to  side  by  con- 
tinuous or  interrupted  suture. 

The  proper  adjustment  of  the  flap  is  clearly  indi- 
cated by  observing"  the  normal  vaginal  contours. 

In  sagittal  section,  the  edge  of  the  posterior  vagi- 
nal wall  presents  an  undulating  line  running  con- 
vexly  in  front  over  the  eminence  of  the  intravaginal 
perineal  crest,  concave  posteriorly  where  it  dips  into 
the  declivity  of  the  posterior  vaginal  cul-de-sac. 

In  the  lacerated  perineum,  on  the  other  hand,  the 
intravaginal  crest  is  obliterated  by  the  diastasis  of 
the  levator  junction,  the  posterior  vaginal  wall  plus 
its  mucosa  is  foreshortened,  and  the  undulation  is 
levelled  to  a  flat  surface. 

The  sutural  reunion  of  the  levator  junction  re- 
stores the  intravaginal  crest  and  the  natural  undula- 
tion of  the  posterior  vaginal  wall. 

The  area  of  an  undulating  surface  is  greater  than 
that  of  a  flat  surface.  It  follow^s  that  the  vaginal 
floor  thus  requires  more  iiiitcosa  after  its  restoration 
than  before.  Moreover,  the  normal  vagina  is  not  a 
canal  of  smooth  bore,  but  rugous. 

To  ablate  the  flap  is  not  only  unanatomical,  but 
unsurgical ;  for,  the  remaining  mucosa,  too  short  to 
adapt  itself  in  lining  the  posterior  or  descending  sur- 
face of  the  intravaginal  crest,  must  span  the  hollow 
at  its  base,  creating  a  dead  space  of  variable  depth 
and  pathological  potentialities. 

To  secure  a  normal  adjustment  of  the  flap,  its 
median  edges  are  brought  together  by  a  thin  catgut 
suture  extending  from  the  central  tip  to  the  lower- 
most hymenal  caruncles,  which  are  thus  brought  into 
their   natural   apposition,   where   the   suture   is   tied. 


142 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  68. — Perineoplasty  (author's  method).  Sutures  introduced 
to  unite  the  musculofascial  layers  superficial  to  the  levator  suture. 
These  sutures  do  not  include  the  levator  muscle. 


LEVATOR    MVORRHAPin'. 


143 


The  resulting  hollow  cone  of  vaginal  mucosa  is  turned 
inside  out,  thus  inverting  its  apex  and  exposing  its 
entire  raw  surface;  this  is  tucked  into  the  vagina,  and 
snugly  applied  against  the  posterior  surface  of  the 
reconstructed  crest  down  to  the  Jiollow  at  its  base, 


P"ig.  69. — Diagram  of  the  vulvoperineal  musculature.  Note  the 
position,  relation,  and  origin  of  the  transversus  perinei  as  com- 
pared with  the  levator  ani. 


where  it  is  retained  by  a  small  packing  of  iodoform 
gauze. 

The  entire  vaginal  canal  is  thus  completely  re- 
stored, and  it  remains  to  readjust  the  levator  fascia 
and  superficial  layers  to  the  cutaneous  perineum. 

The  very  extended  controversy  on  the  relative 
importance  of  fascia  and  muscle  in  gynecic  support 


144 


GYNECOPLASTIC   TECHNOLOGY. 


- — Cenrrum. 
tendi/ieufn 


Sphincter  ej^t 


Fig.  70. — The  transverse  perinei  here  depicted  is  often  mistaken 
for  the  levator  edge.  Isolated  suture  of  these  bundles  give  a  weak, 
insufificient  perineum.      {Doederlein  and  Kroenig.) 


LEVATOR    M^'ORRHAPHV. 


145 


has  only  tended  to  obscure  the  sahent  fundamentals 
of  the  question. 

Physioloi^ically  and  dynamically,  fascia  and 
muscle  constitute  a  functioning  unit.  The  -elastic 
resiliency  of  the  former  is  complemental  to  the  con- 
tractility of  the  latter. 

The   direction   and   arrangement  of   the   muscle- 
fibres  determine  and  limit 

con- 


Fig.  71. — The  fascial  layers  in  relation  to  the  levator  ani. 


tractions,  which  are  amplified  and  extended  radially 
by  its  fascial  sheaths. 

The  exploitation  of  the  fascial  to  the  exclusion 
of  the  direct  levator  suture  in  perineorrhaphy  on  the 
parallel  of  its  utility  in  ventral  hernia  ignores  the 
textural  and  topographic  contrasts  presented  by  the 
two  areas. 

The  abdominal  fascia  ordinarily  ofl:'ers  the  neces- 
sary strength  and  redundancy  essential  to  successful 

10 


146  GYXECOPLASTIC    TECHNOLOGY. 


Fig.  12. — Incorrect  denudation,  leading  into  wrong  cleavage 
lines,  and  necessitating  additional  incisions  into  the  levator  fascia 
to  expose  the  muscle. 


LEVATOR   MYORRHAPHY.  147 

overlapping  in  ventral  hernia,  while  the  pelvic  floor 
fascia  does  not. 

The  torn  levator  fascia,  limited  in  extent  by  its 
firm  attachment  to  the  pubic  arch,  attenuated  by  re- 
traction, and  partly  obliterated  by  cicatricial  fusion, 
does  not  oflfer  the  reconstructive  essentials  to  per- 
manent support.  This  is  substantiated  by  the  short- 
comings in  the  functional  results  of  the  classic  fascial 
perineorrhaphies. 

Efficient  overlapping  is  impossible.  ''A  chain  is 
as  strong  as  its  weakest  link."  Fascial  suture  can- 
not reproduce  fascia,  but  only  an  edge-to-edge  cica- 
tricial junction  at  best. 

An  unbiased  criticism  of  the  results  following  the 
classic  fascial  methods  of  perineorrhaphy  in  vogue 
will  concede  a  more  or  less  perfect  cosmetic  restora- 
tion of  perineal  contours  and  bulk,  in  which,  how^- 
ever,  the  all-essential  physiologic  muscular  element 
in  pelvic  support  is  supplanted  and  immobilized  by  a 
vicarious  cicatricial  plug  at  the  vaginal  outlet. 

Such  result  fulfills  all  the  indications  for  those 
who  continue  to  see  a  "perineal  body  forming  a  tri- 
angular wedge,  composed  of  fascia  and  areolar  tis- 
sue," instead  of  a  muscular  pelvic  floor,  and  who 
still  adhere  to  the  theory  that  ascribes  the  role  of 
the  perineum  in  the  co-ordination  of  gynecic  support 
to  form  rather  than  function. 

Obstructive  retention  at  the  vaginal  outlet  can- 
not permanently  replace  normal  physiologic  support, 
and  the  aim  in  perineorrhaphy  must  be  the  restitu- 
tion of  such  anatomic  relations  as  to  restore,  as  far 
as  possible,  physiological  as  \vell  as  mechanical 
support  to  the  pelvic  contents. 


148 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  72>. — Inporrect  exposure  and  improper  suture  of  the  levator 
ani.  The  levator  edges  are  here  drawn  through  a  slit  in  its 
fascia,  resulting  in  a  thin  cicatricial  crescentric  diagram  at  the 
vulvar  outlet.       ■■ 


LEVATOR    MYORRHAPHY.  I49 

The  original  perineal  rent  is  anteroposterior. 
Subsequent  levator  retraction  converts  this  sagittal 
rent  into  a  transverse  slit.  The  operative  denuda- 
tion and  properly  applied  anteroposterior  traction  by 
tenacula  reconverts  the  transverse  wound  into  a 
perpendicular  slit,  which  thus  restores  the  original 
relations  of  the  fascial  edges  for  suture  in  the  median 
line. 

Whether  the  fascial  structures  and  skin  are 
finally  united  by  one  or  two  rows  of  interrupted 
sutures  is  simply  a  matter  of  individual  preference, 
the  main  object  being  accurate  layer  coaptation. 

The  interposed  levator  muscle  in  the  rectovaginal 
septum  provides  contractile  resistance  over  the  two 
hernial  areas  in  the  vaginal  canal — namely,  the 
uterovesical  above  and  the  uterorectal  below — ful- 
filling its  function  in  gynecic  support,  and  restormg 
the  anatomic  contours  of  the  lacerated  perineum. 


CHAPTER  XIV. 

The  Retrodisplaced  Uterus  as  a  Complication 
IN  Pelvic  Floor  Injury. 

The  development  of  uterine  prolapse  consequent 
upon  a  perineal  laceration  is  invariably  preceded  by 
a  stage  of  retroversion. 

On  the  other  hand,  every  retroverted  uterus 
does  not  necessarily  prolapse.  A  concomitant 
cervical  laceration,  chronically  infected  and  pro- 
ductive of  adnexal  disease  with  peri-uterine  adhe- 
sions, may  suspend  the  uterus  and  prevent  its 
ultimate   descent. 

The  treatment  of  retroversion  is  the  correction 
of  its  cause. 

The  cause  may  be  congenital  or  acquired. 

Our  fundamental  conceptions  of  uterine  poise, 
normal  and  abnormal,  have  not  as  yet  attained  to 
any  concrete  finality,  and,  barring  the  occasional 
allusion  to  the  existence  of  congenital  retrodisplace- 
ments  and  their  probable  dependence  upon  conditions 
of  general  visceroptosis,  the  clinical  significance  of 
such  displacements,  and  their  diagnostic,  etiologic, 
and  therapeutic  contrast  to  the  acquired  form,  find 
no  elucidation  in  the  literature  on  the  subject. 

The  wide  diversity  in  the  nature  of  the  two  con- 
ditions, presenting  practically  identical  symptoms, 
demands  their  clinical  differentiation.  Such  differ- 
(150J 


THE  RETRODISPLACED  UTERUS.  151 

entiation  necessitates  a  differentiating  factor  of  pa- 
thognomonic constancy. 

A  uterus  congenitally  retroposed  before  impreg- 
nation will  resume  its  retroposition  after  delivery, 
whether  the  pelvic  floor  is  lacerated  or  not. 

Loss  of  perineal  support  in  the  congenital  class 
is  more  prone  to  the  development  of  procidentia  than 
in  the  acquired  form. 

The  correction  of  congenital  retroposition  as  such 
is  essentially  orthopedic,  while  that  of  the  acquired 
form  is  gynecologic.  Hence  this  differentiation  is 
important. 

Approximately,  i8  per  cent,  of  all  gynecological 
patients  present  a  retrodisplaced  uterus. 

Barbour  and  Watson  estimate  one-fifth  of  this 
number  as  congenital  in  origin,  qualifying  their 
statement,  however,  by  admitting  that  "it  is  difficult 
to  establish  the  congenital  nature  of  these  cases;  but 
should  a  uterus  be  found  retroverted  in  a  nulliparous 
patient,  without  any  history  of  inflammation  or  other 
cause  sufflcient  to  produce  retroversion,  should  it 
measure  only  25^  inches  by  sound,  and  on  being  re- 
placed show  a  tendency  to  resume  its  retroverted 
poise,  we  are  justified  in  assuming  that  it  has  de- 
veloped in  that  position." 

These  admittedly  vague  differential  criteria  em- 
body in  their  very  paucity  the  crux  of  the  clinical 
problem  presented  by  uterine  displacements  in  gen- 
eral to-day. 

In  the  first  place,  a  retrodeviated  uterus,  whether 
in  a  nulliparous  or  multiparous  patient,  "without 
evidence  of  inflammation  or  other  cause  sufficient  to 
produce  the  displacement,"  would  be  classified  as  a 


152 


GYXECOPLASTIC   TECHNOLOGY. 


Fig.  74. — Normal  or  neutral  type  of  posture.  Distinguishing 
features  are:  (1)  Line  of  gravity  of  body  passes  through  impor- 
tant pivotal  points;  (2)  the  pelvis  is  balanced  in  equilibrium  on 
the  heads  of  the  thigh  bones;  (3)  this  relation  of  important 
pivotal  points  with  the  line  of  gravity  and  this  balance  of  the  pelvis 
prevents  muscle  and  ligament  strains ;  and  (4)  the  rear  perpen- 
dicular touches  the  middle  back  and  the  buttocks.  (Modified  from 
Dickinson  and  Truslow.) 


THE  RETRODISPLACED  UTERUS. 


153 


Fig.  75. — A,  Kangaroo  type  of  posture.  Distinguishing  features 
are:  (1)  Most  pivotal  structures  of  the  trunk  are  carried  in  front 
of,  and  those  of  the  lower  extremities  behind,  the  line  of  gravity ; 
(2)  the  pelvis  rotates  forward  downward;  (3)  the  forward  carried 
trunk  puts  strain  on  the  spinal  and  pelvospinal  ligaments  and 
muscles,  and  tends  towards  forward  displacement  of  abdominal 
and!  pelvic  viscera.  Wavy  lines  indicate  muscles  relaxed;  double 
lines,  muscles  in  action.  B,  Gorilla  type  of  posture.  Distinguish- 
ing features  are:  (1)  Most  of  the  pivotal  structures  of  the  trunk 
are  carried  back  of,  and  those  of  the  lower  extremities  in  front  of, 
the  line  of  gravity;  (2)  the  pelvis  rotates  backward  downward;  (3) 
the  backward  carried  trunk  puts  its  own  variety  of  strain  on  the 
spinal  and  pelvospinal  ligaments  and  muscles,  and  tends  toward 
backward  and  downward  displacement  of  the  abdominal  and  pelvic 
viscera.  Wavy  lines  indicate  muscles  relaxed ;  double  lines,  in 
action.     (Modified  from  Dickinson  and  Truslow.) 


154  GYNECOPLASTIC   TECHNOLOGY. 

simple  or  uncomplicated  malposition,  regardless  of 
its  probable  congenital  nature. 

Such  classification  has  a  most  significant  thera- 
peutic bearing,  for,  accepting  the  clinical  postulate, 
that  all  uncomplicated  uterine  retrodisplacements  are 
devoid  of  symptoms  or  clinical  significance,  it  follows 
that  to  differentiate  the  congenital  from  the  acquired 
retrodisplacements  is  to  exclude  any  attempt  at  cor- 
rection of  the  displacement  as  such  in  over  one-fifth 
of  the  cases. 

On  the  other-  hand,  a  congenitally  retrodisplaced 
uterus  is  not  necessarily  "nuUiparous,"  nor  immune 
to  "inflammatory  and  other  complications  capable  of 
producing  retroversion."  It  may,  like  any  other 
uterus,  measure  more  than  ''2)4  inches  by  sound," 
so  that  the  congenital  origin  of  its  retroposition 
must  be  established  through  existing  diagnostic 
factors  that  are  constant  and  remain  unaltered  by 
complicating  elements  which  tend  to  efface  the 
characterizing  syndrome  formulated  by  Barbour 
and  Watson. 

As  a  matter  of  fact,  it  is  that  very  class  of  pa- 
tients, with  their  congenital  deviations  obscured  by 
superposed  parturitional  and  infectious  complications, 
in  which  differentiation  is  most  essential. 

In  seeking  to  establish  such  a  constant  pathog- 
nomonic factor  it  is  necessary  to  recognize  that  the 
malposition  does  not  represent  simply  a  congenital 
uterine  retroversion,  but  a  congenital  retroversion  of 
the  entire  pelvis,  with  resultant  compensatory  dys- 
topia of  its  contents. 

Dickinson  and  Truslow  characterize  the  general 
skeletal  poise  of  these  cases  as  "the  gorilla  type,"  in 


THE  RETRODISPLACED  UTERUS. 


155 


which  "the  pelvis  is  rolled  or  rotated  backward  and 
downward,  the  plane  of  its  inlet  making  with  the 
horizon  an  angle  more  acute  than  that  of  the  normal 
type." 

In  other  words,  with  normal  spinal  contours,  the 
axes  of  the  abdominal  and  pelvic  cavities  form  al- 


Fig.  76. — A,  Axis  of  abdominal  cavity.    B, 
Axis  of  pelvic  cavity. 

most  a  right  angle,  while  in  the  stature  under  con- 
sideration there  is  a  marked  flattening  of  the  sacro- 
vertebral  angle,  resulting  in  an  approximation  of 
these  axes  toward  the  vertical,  so  that  the  thrust  of 
intra-abdominal  pressure  is  expended  in  a  more 
direct  line  on  the  pelvic  viscera. 

This    flattening   of    the    sacrovertebral    angle,    is 


156  GYNECOPLASTIC   TECHNOLOGY. 

regularly  evidenced  by  a  corresponding  obliteration 
of  the  normal  lumbar  curve,  and  the  measure  of  its 
resultant  approximation  to  the  vertical  constitutes  a 
diagnostic  index  in  differentiating  congenital  from 
acquired  retrodisplacements  of  the  uterus. 

To  obtain  this  measure,  the  patient,  with  back 
exposed,  assumes  her  natural  standing  attitude,  while 
the  edge  of  an  ordinary  1 8-inch  desk  ruler,  held 
vertically  in  contact  with  the  most  prominent  spinous 
processes  of  the  dorsal  and  sacral  convexities,  spans 
the  intervening  lumbar  hollow. 

The  distance  in  millimeters  from  the  deepest 
point  of  this  hollow  to  the  edge  of  the  ruler  presents 
our  index. 

The  spinous  processes  of  the  dorsal  and  sacral 
convexities  are  invariably  and  distinctly  palpable 
under  all  degrees  of  adiposity  and  statural  deviations, 
while  the  extreme  simplicity  of  the  method  and  means 
enables  anyone  to  substantiate  the  uniform  accuracy 
of  the  index,  and  elicit  the  significance  and  indications 
of  its  clinical  bearings. 

In  an  extensive  series  of  observations,  the  index 
ranged  from  12  to  45  millimeters.  An  excess  of  45 
millimeters  indicates  pathological  lordosis — a  con- 
dition the  opposite  to  that  under  consideration,  of 
more  obstetric  and  less  gynecological  importance. 

An  index  of  30  millimeters  marks  the  extreme 
minimum  compatible  with  normal  anteversion  of 
the  uterus.  From  25  millimeters  down,  the  exist- 
ence of  congenital  retroversion  may  he  positively 
predicated  in  nearly  every  case  prior  to  its  biman- 
nal  verification,   and  this  regardless  of  multiparity 


THE  RETRODISPLACED  UTERUS. 


157 


1/ 


Fig.  77. — The  edge  of  an  18-inch  ruler  held  vertically  in  con- 
tact with  the  most  prominent  spinous  processes  of  the  dorsal  and 
sacral  convexities  spans  the  lumbar  hollow.  The  distance  in 
millimeters  from  the  deepest  point  of  the  hollow  to  the  anterior 
edge  of  the  ruler  presents  the  '"lumbar  index."     (. Author's  method.) 


158 


GYNECOPLASTIC   TECHNOLOGY. 


and  the  other  complicating  factors  that  obliterate 
the  differentiating  criteria  formulated  by  Barbour 
and   Watson. 

A  uterus  congenitally  retroverted  before  concep- 
tion will  invariably  resume  its  retroverted  position 
after  delivery,  when  the  demonstration  of  a  minus 
index  will  reveal  the  congenital  nature  of  the  dis- 
placement, to  the  exoneration  of  the  accoucheur. 


Fig.  7S. — Diagram  of  the  relation  of  pelvis  to  abdomen.  A, 
Sacrolumbar  angle.  B,  Upper  sacral  vertebra.  D-E,  Line  extend- 
ing from  the  upper  symphyseal  border  to  the  sacrococcygeal 
joint. 


The  application  of  the  lumbar  index  will  establish 
over  one-half  of  all  retroversions,  complicated  and 
uncomplicated,  as  congenital,  instead  of  one-fifth,  as 
hitherto  accepted. 

The  rare  exceptions  to  the  rule  will,  on  closer  in- 
vestigation, reveal  an  exostosis  of  the  sacral  promon- 
tory; a  recession  of  the  pubes  which  foreshortens  the 
conjugate  diameter;  a  strained  and  deceptive  pose 
assumed  by  the  patient  during  measurement,  or  an 


THE  RETRODISPLACED  UTERUS.  159 

acquired  autcz'crsion  from  pathological  concomitants, 
for  it  is  only  reasonable  to  suppose  that,  just  as  a 
normally  poised  uterus  may  be  retroverted,  so  a  con- 
genitally  retroverted  one  may  become  anteverted 
without  invalidating  the  utility  of  the  index. 

It  must  be  emphasized,  that  congenital  retrover- 
sion, as  such,  is  essentially  only  a  part  of  a  compen- 
satory adaptation  of  the  pelvic  contents  to  abnormal 
static  conditions  through  unstable  spinal  poise;  that 
the  depth  of  the  lumbar  hollow  is  the  relative  measure 
of  the  sacrovertebral  angle ;  that  the  degree  of  sacro- 
vertebral  angulation  determines  the  dip  of  the  pelvis, 
and  that  a  certain  degree  of  such  pelvic  dip  is  essen- 
tial to  the  normal  topography  of  its  contents. 

A  fiat  sacrolumbar  angle  with  vertical  pelvis  is 
normal  in  early  childhood,  but  abnormal  in  the  adult. 

If  an  infant  be  placed  on  its  back,  and  its  legs 
be  drawn  down  from  their  habitual  attitude  of  semi- 
flexion, it  will  be  noticed  that  the  range  of  extension 
is  limited  by  the  absence  of  the  lumbar  curve  and 
pelvic  incline.  When  gain  in  muscular  development 
enables  the  infant  to  stand,  the  erector  spinse  draws 
the  trunk  upward  against  the  resistance  of  the  ilio- 
psoas group  and  ligaments  of  the  hip-joint,  bending 
the  lumbar  spine  into  its  physiological  curve. 

In  other  words,  under  normal  development,  the 
erect  attitude  is  attained  by  flexure  of  the  lumbar 
spine,  the  pelvis  maintaining  an  incline  of  60  to  65 
degrees,  the  tip  of  the  coccyx  being  on  a  level  with 
the  lower  border  of  the  symphysis  pubes.  Under  ab- 
normal developmental  conditions,  the  upright  pose  is 
induced  principally  by  an  upward  and  backward  rota- 
tion of  the  pelvis  on  the  hip-joints,  carrying  the  axis 


160  GYXECOPLASTIC   TECHNOLOGY. 

of  its  inlet  toward  a  vertical  from  a  horizontal 
line. 

In  such  a  vertical  pelvis,  the  only  tenable  position 
for  the  uterus  is  one  of  retroposition. 

The  upward  and  backward  rotation  of  the  pelvis 
elevates  the  pubes  and  lowers  the  sacrum,  which  lat- 
ter, thus  forming  the  posterior  instead  of  the  upper 
wall  of  the  pelvic  cavity,  necessarily  alters  the  mech- 
anism of  the  sacro-uterine  ligaments,  their  horizontal 
pull  tending  to  hold  the  uterus  backward  against 
the  depressed  sacrum,  instead  of  suspending  it  from 
above,  as  in  the  normal.  Furthermore,  intra-abdomi- 
nal pressure,  inadequately  deflected,  thrusts  the  loose 
intestinal  coils  into  the  pelvic  cavity  and  against  the 
anterior  surface  of  the  uterus,  crowding  it  into  the 
space  of  least  resistance  offered  by  the  sacral  hollow. 
To  put  it  tersely,  every  fixed  abnormal  pelvic  tilt 
must  create  a  correspondingly  abnormal  uterine 
tilt. 

The  whole  clinical  import  of  congenital  retro- 
versions is  centered  in  their  intra-  and  extra-pelvic 
complications,  not  in  the  uterine  displacement  as 
such. 

The  continuous  attitudinal  strain  on  the  sacroiliac 
joints,  the  erector  spinse  and  iliopsoas  muscles,  in- 
duces pelvic  symptoms  that  simulate  and  are  gener- 
ally attributed  to  the  retroversion. 

Operative  gynecolog}^  to  date  records  over  lOO 
detailed  methods  for  the  correction  of  uterine  retro- 
displacements.  Every  one  of  these  methods,  at  the 
hands  of  its  promulgator,  will  undoubtedly  convert 
the  retroposed  into  an  anteroposed  uterus;  but  not- 
withstanding their  faultless  uterine  poise,  many  of 


THE  RETRODISPLACED  UTERUS.  161 

these  patients  will  continue  to  suffer  as  before  opera- 
tion— and  some  more  so. 

Baldy  states:  "In  my  opinion  nine-tenths  of  the 
operations  performed  on  women  for  retrodisplace- 
ments  are  uncalled  for;  and,  further,  the  possible 
number  of  retrodisplacement  operations  performed 
in  this  country  is  limited  only  by  the  number  of 
females  in  existence." 

We  have  already  stated  that  congenital  retrover- 
sion is  a  compensatory  necessity,  and  it  follows  that 
any  procedure  which  converts  such  a  retroversion 
into  an  anteversion  converts  a  compensated  into  a 
decompensated  visceral  equilibrium  within  the  pelvic 
cavity. 

Clinically,  the  lumbar  index  will  reveal  two  classes 
of  congenital  retrodisplacements,  namely,  the  com- 
plicated and  the  uncomplicated. 

Leaving  the  retroversion,  as  such,  unmolested, 
the  gynecologist  should  aim  to  eradicate  all  coexist- 
ing intrapelvic  complications,  thus  converting  the 
complicated  into  an  uncomplicated  case. 

It  cannot  be  overemphasized  that  patients  with 
uncomplicated  congenital  retroversion  suffer  through 
a  constant  attitudinal  strain  in  maintaining  their 
unstable  skeletal  poise  within  the  lines  of  gravity, 
the  congenital  retrodisplacement  of  the  uterus 
being  an  accompaniment  and  not  a  cause  of  the 
suffering. 

These  cases  must  be  treated  on  purely  mechanical 
and  orthopedic  principles,  the  details  of  which  find 
full  elaboration  in  the  appended  literature. 

The  normal  uterine  poise  is  necessarily  oscillat- 

11 


162  GYNECOPLASTIC   TECHNOLOGY. 

ing,  the  fundus  traversing  an  anteroposterior  arc 
whose  normal  Hmits  extend  from  the  symphysis  pubes 
to  the  sacral  promontory,  with  its  axis  of  oscillation 
at  the  cervicocorporeal  junction,  its  pivotal  fixation 
secured  by  the  so-called  "cardinal  ligament." 

The  round  ligaments  tend  to  subserve  uterine 
support  only  in  so  far  as  they  limit  its  essential 
mobility  to  a  normal  range.  They  maintain  poise,  hut 
not  support.  They  cannot  lift  the  uterus,  because 
their  insertion  at  the  fundus  is  normally  above  their 
pelvic  attachment;  hence  their  pull  on  the  fundus  is 
downward  and  forward. 

Whether  the  uterus  oscillates  from  promontory 
toward  symphysis,  as  in  congenital  retroposition,  or 
vice  versa,  as  in  the  normal,  is  a  phenomenon  of 
clinical  indifference  so  long  as  the  elevation  of  the 
pivotal  point,  which  is  determined  by  the  plane  of  the 
levator  junction,  is  at  the  normal  level.  Poise  is 
unimportant;  elevation  is  essential. 

Every  uterus  freely  movable  at  the  normal  pelvic 
level  is  in  normal  poise  at  any  point  in  its  arc  of 
transit  from  the  symphysis  to  the  sacral  promontory. 

Briefly  summarized,  congenital  retropositions 
should  not  be  corrected. 

Acquired  retroversions  without  descensus,  result- 
ing from  levator  impairment,  are  corrected  by  levator 
myorrhaphy. 

Acquired  retroversions  with  descensus  should 
be  corrected  by  levator  myorrhaphy  plus  a  vaginal 
shortening  of  the  round  ligaments,  which  pulls  the 
uterus  forward  out  of  the  sacral  hollow  and  upon  its 
re-established  levator  fulcrum.     Finally,  all  adherent 


THE  RETRODISPLACED  UTERUS.  163 

retroversions  should  be  attacked  through  the  abdom- 
inal route. 

As  the  vaginal  shortening  of  the  round  ligaments 
should  constitute  a  part  of  every  cystocele  operation, 
it  will  obviate  repetition  to  detail  the  method  under 
the  latter  caption. 


CHAPTER  XV. 

Cystocele. 

Clinically,  it  is  essential  to  differentiate  the 
simple  ectopia  of  the  vaginal  wall,  known  as  anterior 
colpocele,  from  the  condition  of  true  cystocele. 


Fig.  79. — Anterior  colpocele  simulating  cystocele.  Dotted  line 
indicates  the  redundant  anterior  vaginal  wall,  with  the  bladder  and 
urethra  in  normal  position. 

Anterior  colpocele  occurs  as  a  result  of  certain 
obstetric  complications  that  lead  to  separation  and 
prolapse  of  the  vaginal  v\^all  from  the  vesical  base 
without  disturbing  the  musculofascial  planes  that 
maintain  the  anatomic  position  and  topographic  re- 
lations of  the  bladder. 
(164) 


CYSTOCELE. 


165 


The  abnormality,  with  but  few  exceptions,  occurs 
in  parous  women  during  the  first  and  second  decades 
of  the  child-bearing  period.  A  coexisting  lesion  of 
the  pelvic  floor  may  or  may  not  be  present,  although 
a  lacerated  or  relaxed  state  of  these  structures  al- 
ways aggravates  the  condition,  and  in  exceptional 
cases  bears  a  causal  relation  to  its  development. 


P'ig.  80.— Urethrocele.     B,  Bladder.     U,  Urethrocele. 


First  among  the  distinguishing  features  between 
anterior  colpocele  and  true  cystocele  is  the  absence  of 
uterine  ptosis;  in  fact,  the  uterus  bears  no  relation 
w^hatever  to  either  the  production  or  maintenance  of 
an  existing  colpocele,  while,  on  the  other  hand,  a  true 
cystocele  without  uterine  descent  is  anatomically  in- 
conceivable. 

Such  a  uterine  descent  may  not  be  evident  unless 
the  patient  is  examined  in  the  erect  posture. 


166 


GYNECOPLASTIC   TECHNOLOGY. 


True  cystocele  dififers  from  colpocele  as  a  loose 
fold  of  hypertrophied  skin  or  relaxed  abdominal  wall 
differs  from  ventral  hernia. 

The  prolapsed  vaginal  wall  is  usually  hypertro- 


Fig.  81. — Inversion  of  the  vagina,  with  cystocele  and  pro- 
cidentia uteri.     Catheter  in  bladder. 


phied  and  rugous,  while  the  vaginal  covering  of  a 
cystocele,  especially  when  distended,  is  smooth  and 
thin.  Furthermore,  careful  palpation  will  disclose  the 
mobiHty  of  the  simple  vaginal  protrusion  on  the  firm 


CYSTOCELE. 


167 


subjacent  vesical  floor.  In  cystocele  a  catheter  passed 
into  the  bladder  can  be  directed  so  that  the  vesical 
end  of  the  catheter  may  be  felt  in  the  prolapsed  blad- 
der, where  it  protrudes  throu.^h  the  vaginal  outlet. 

Residual   urinary   retention   and   its   possible   se- 
quella  are  conspicuously  absent  in  colpocele. 


Fig.  82. — Initial  direction  of  intra-abdominal  pressure 
at  the  pelvic  brim. 


Anterior  colpocele,  involving  the  vaginal  mucosa 
only,  is  curable  by  any  of  the  standardized  colporrha- 
phies  that  simply  ablate  a  varying  patch  of  the  vagi- 
nal mucosa,  and  reef  the  wound  edges  by  suture. 
^  A  herniated  bladder,  however,  cannot  possibly  be 
restored  and  retained  by  any  such  procedure,  which 
only  substitutes  a  yielding  temporary  occlusion  for 
the  mechanism  of  physiological  support. 


168  GYNECOPLASTIC   TECHNOLOGY. 

Notwithstanding  these  dinical,  pathological,  and 
surgical  contrasts  between  the  two  conditions,  the 
term  cystocele  is  still  generally  applied  to  all  pro- 
trusions of  the  anterior  vaginal  wall  regardless  of 
the  structures  involved.  Thus  we  find  (Kelly  and 
Noble's  Gynecology)  "anterior  colporrhaphy  or  re- 
section of  the  anterior  vaginal  wall  is  indicated  for 
the  cure  of  cystocele,  or  of  cystocele  complicated  by 
prolapse  of  the  uterus;"  and  again,  "anterior  colpor- 
rhaphy is  the  only  satisfactory  treatment  for  cys- 
tocele." 

More  recently,  Robert  Frank  epitomizes  the  sub- 
ject to  date  in  the  following:  "The  writer  has  seen 
individual  operators  who,  through  long  years  of  ex- 
perience, or  by  reason  of  special  gifts  and  dexterity, 
have  acquired  the  necessary  skill,  but  who  were  quite 
unable  to  teach  to  the  spectator,  or  even  transmit  to 
their  regular  assistants  the  method  by  which  they  ob- 
tained their  good  results.  This  inability  to  teach  is 
due  to  the  fact  that  these  operators,  although  by 
nicety  of  judgment,  by  precision  of  execution,  by 
unconscious  visualizing  of  reconstruction,  and  by 
proper  extent  of  denudation  they  obtained  good  re- 
sults, did  not  expose  the  field  anatomically,  and  did 
not  perform  an  anatomical  repair,  such  as  is  done 
as  a  matter  of  course  in  inguinal  herniotomy,  for 
example.  .  .  .  For  a  number  of  years  the  so-called 
interposition  operation  has  been  employed  in  the 
treatment  of  cystocele.  This  procedure  is  anatomical 
in  so  far  as  its  execution  is  concerned,  but  the  result- 
ing repair  distorts  natural  conditions  to  a  degree 
which  necessitates  sterilization,  if  performed  in  the 
child-bearing  period,  and  is  unsatisfactory  when  ap- 


CVSTOCELE.  169 

plied  to  cases  of  prolapse.  .  .  .  The  majority  of 
operations  devised  for  cystocele  and  rectocele  depend 
upon  ingenious  denudation,  complicated  application 
of  sutures,  etc.,  rather  than  upon  a  firm  anatomical 
basis." 


Fig.  83. — Diagrammatic  scheme  of  misdirected  pressure  deflec- 
tion by  deranged  intrapelvic  planes,  due  to  incompetent  levator 
contraction  resulting  from  perineal  injury.  The  same  occurs  as 
a  result  of  levator  paralysis  in  Spina  bifida  occulta,  or  lesions  of 
the  fourth  sacral  nerve  producing  a  "virginal  uterine  prolapse," 
notwithstanding  intact  fascia  and  ligaments.  First  stage  in  the 
development  of  cystocele  and  procidentia  uteri. 

A  rational  operative  procedure  for  the  cure  of 
cystocele  must  be  evolved  from  a  clear  conception  of 
the  disorder  in  the  supporting  mechanism  resulting 
in  prolapse. 

Although    descriptive    anatomy    enumerates    five 


170 


GYNECOPLASTIC   TECHNOLOGY. 


''true"  and  five  ''false"  ligamentous  supports,  the 
bladder  is  actually  swung  at  its  base  on  a  thin 
fascial  hammock,  which  extends  from  the  posterior 
surface  of  the  symphysis  and  pubic  rami  to  the  cer- 
vicocorporeal  junction  of  the  uterus. 


Fig.  84. — Perineal  laceration,  with   rectocele  leucorrhea, 
from  chronic  endocer\-icitis. 

The  anterior  or  pubic  extremity  of  the  bladder 
base  thus  presents  a  fixed  point,  while  its  posterior 
or  cervical  segment  naturally  participates  in  the 
mobility  of  the  uterus.  Uterine  poise  thus  dominates 
bladder  poise;  the  free  span  of  bladder  base  between 
the  pubic  and  cervical  attachment  and  its  subjacent 


CYSTOCELE. 


171 


anterior  vaginal  wall   being  supported  by  the  mus- 
culofascial  mechanism  of  the  pelvic  floor. 

In    applying    the    principle    of    deflection    to    the 
problem  of  intrapelvic  visceral  support,  as  elucidated 


Fig.  85. — Procidentia  uteri.  A,  Cystocele,  showing  transverse 
rugse,  the  lowermost  of  which  indicate  the  position  of  the  lower 
bladder  pole.     B,  Endocer^'ical  ulceration.     C,  Rectocele. 

in  the  chapter  on  perineorrhaphy,  intra-abdominal 
pressure  is  defined  as  the  initial  force  to  be  deflected, 
the  mobile  intestinal  coils  as  the  medium  through 
which   this    force   is   manifested,   and   the   muscular 


172  GYNECOPLASTIC   TECHNOLOGY. 

mechanism  of  the  pelvic  floor  plus  its  superposed 
bladder  and  uterus  as  the  deflecting  plane. 

A  transverse  section  of  the  empty  bladder  is 
Y-shaped,  due  to  the  cupping  of  its  summit  in  con- 
traction. 

"As  the  bladder  empties,  the  upper,  more  mov- 
able portion,  covered  with  peritoneum,  settles  down 
into  the  lower  and  relatively  more  fixed  portion,  un- 
til it  comes  to  lie  within  it  as  one  saucer  rests  in 
another.  During  respiration  the  free  upper  half  may 
be  seen  (through  the  cystoscope)  moving  on  the 
lower  half,  as  if  hinged,  the  line  of  demarcation  be- 
tween them  being  distinctly  visible. 

"At  the  edges  where  the  two  saucers  meet,  three 
folds  are  formed — the  right,  left,  and  posterior.  The 
posterior  fold  stretches  from  side  to  side  in  front  of 
the  uterus;  it  is  gently  convex  forward,  following 
the  contour  of  the  uterus,  and  ends  in  front  of  each 
broad  ligament,  where  each  lateral  fold  begins  and 
extends  horizontally  around  toward  the  urethra. 
These  folds  represent  the  physiological  hinges  on 
which  the  bladder  moves  in  expanding  and  collapsing. 

"The  apices,  where  the  posterior  fold  joins 
the  lateral  fold  in  front  of  the  broad  ligaments,  are 
called  the  right  and  left  vesical  cornua"  (Howard 
Kelly). 

This  is  significant,  for  under  normal  conditions 
the  concavity  of  its  intraperitoneal  aspect,  induced 
by  this  cupping,  is  filled  by  the  convex  uterine  fundus 
like  a  ball  in  a  socket,  which  thus  maintains  the  con- 
tours and  incline  of  the  plane  for  the  deflection  of 
pressure  from  above.  On  the  other  hand,  where  the 
uterine    fundus    is    retroverted    and    prolapsed,    the 


CYSTOCELE.  173 

cupped  bladder  area  affords  a  potential  peritoneal 
pouch  for  the  herniation  of  its  superposed  intestine.^ 

Observing  the  distorted  topography  of  the  pelvic 
viscera  from  above  in  a  case  of  marked  cystocele,  the 
first  abnormality  to  obtrude  itself  is  the  absence  of 
the  uterine  fundus  from  its  normal  situation,  and  the 
presence  in  its  place  of  intestinal  coils.  On  clearing 
these  coils,  the  essential  incline  of  the  pelvic  floor  is 
found  converted  into  a  hollow  declivity  formed  by 
the  distended  uterovesical  space,  with  the  uterine 
fundus  posteriorly,  and  the  bladder  at  the  bottom. 
The  crippled  levator  ani  permits  the  anterior  part  of 
the  pelvic  floor  to  sag,  levelling  its  incline;  the  direc- 
tion of  intra-abdominal  pressure,  no  longer  deflected, 
falls  upon  the  vesico-uterine  space,  which,  deprived 
of  its  musculofascial  buttress  at  the  perineal  crest, 
becomes  pouched  and  distended  with  intestinal  coils. 

Thus  the  fully  developed  cystocele  represents  not 
merely  a  prolapse  of  the  bladder,  but  a  complete 
hernia,  equipped  with  its  peritoneal  sac  containing 
intestine,  differing  from  an  inguinal  hernia  only  in 
that  the  bladder  and  vaginal  zvall  enter  into  the  for- 
uiation  of  its  coverings. 


CHAPTER  XVI. 

Operations  for  Cystocele. 

The  surgical  object  in  the  cure  of  cystocele  and 
procidentia  should  not  aim  to  create  merely  a  cica- 
tricial retention  of  the  prolapse  at  the  vaginal  outlet, 
but  to  reconstruct  the  mechanism  which  exercises 
physiological  support  from  below  and  deflects  pres- 
sure from  above  the  pelvic  organs. 

That  this  object  is  not  uniformly  attained  is  ap- 
parent in  the  diversity  and  multiplicity  of  prevailing 
methods. 

The  procedure  of  Bumm,  Liepman,  and  Martin, 
which  consists  of  a  simple  anterior  colporrhaphy  re- 
inforced by  separate  suture  of  the  subvesical  fascia, 
after  mobilizing  the  bladder,  is  advocated  and  de- 
tailed by  Frank  in  the  following : — 

"The  cervix  is  grasped  with  a  vulsellum  forceps, 
and  forcibly  pulled  downward.  A  small  forceps 
(Ochsner)  is  applied  to  the  mucosa  Yz  centimeter  be- 
low the  urethra.  A  vertical  incision,  just  penetrating 
through  the  vaginal  mucosa,  is  made  between  the  two 
instruments.  Starting  from  below  upward,  the  vag- 
inal mucosa  is  separated  from  the  underlying  bladder 
for  a  distance  of  only  )4  centimeter  along  the  entire 
edge  on  both  sides  of  the  incision.  The  vaginal  flap 
is  made  as  thin  as  possible.  To  each  edge  two 
Ochsner  forceps  are  applied  as  tractors.  At  the  very 
bottom  of  the  incision  a  few  snips  of  a  blunt  scissors 
(174) 


OPERATIOXS  FOR  CVSTOCELE. 


175 


cut    across    the    so-called    'vesical    ligament,'    which 
serves  to  attach  the  bladder  to  the  cervix. 

"The  gauze-covered  finger,  by  stripping  upward 
and  backward,  strictly  in  the  median  line,  now  frees 
the  lower  margin  of  the  bladder  from  the  cervix. 
As  this  is  done  on  each  side,  fascial  fibres  running 
upward  and  inward  become  apparent.    These  are  the 


Fig.  86. — "Bladder  pillars."     A,  Pubocervical 
ligament.     (From  life.) 

'bladder  pillars'    (the  pubovesical  ligaments),  which 
are  invaluable  in  the  repair. 

"Not  until  this  dissection  has  been  completed  is 
it  wise  to  separate  the  vaginal  mucosa  to  the  neces- 
sary distance  laterally,  because  it  is  extremely  easy 
to  stray  into  a  deeper  layer,  and  thus  either  destroy 
or  repeatedly  buttonhole  the  'pillars'  and  the  thin  fas- 
cia which  covers  them,  or  to  detach  them  from  their 


176 


GYNECOPLASTIC   TECHNOLOGY. 


continuity  with  deeper  structures    (anterior  part  of 
cardinal  ligament). 

"After  the  vaginal  flaps  have  been  reflected,  and 
the  bladder  pushed  up  well  above  the  peritoneal  re- 
flection, especially  at  the  sides   (behind  the  pillars), 


Fig.  87. — Operation  for  cystocele.  Exposure  of  the  "bladder 
pillars"  (pubocervical  ligament)  and  insertion  of  the  cervical 
sutures.     (Frank.) 

interrupted  sutures  of  chromic  gut  are  passed  from 
side  to  side,  entering  one  pillar,  then  catching  the 
cervix,  and  again  taking  in  the  pillar  of  the  opposite 
side. 

"The  upper  suture  must  be  passed  with  care,  and 
not  too  deeply,  as  the  ureters  are  in  close  proximity. 


OPERATIONS  FOR  CYSTOCELE. 


177 


''When  these  sutures  are  tied,  the  bladder  is  held 
well  up  and  back,  and  is  prevented  from  descending. 

"At  the  upper  end  of  the  denudation,  close  to 
the  urethra,  a  strong  inverted  V-shaped  fascia  will 
be  noted.     This  forms  part  of  the  anterior  layer  of 


Fig.  88. — Cystocele  operation.    Cervical  sutures  tied,  holding  back 
bladder.    Insertion  of  more  anterior  suture.     (Frank.) 

the  triangular  ligament.  AMien  this  is  approximated 
by  transverse  or  mattress  sutures  of  chromic  gut, 
only  a  small  portion  of  the  bladder  between  the  upper 
and  lower  sutured  areas  lacks  reinforcement.  This 
weak  spot  can  now  be  closed,  as  the  fascial  edges, 
which  have  become  demarcated  far  laterally  by  the 

12 


178  GYNECOPLASTIC   TECHNOLOGY. 

traction  of  the  tied  sutures  (and  which  draw  the 
anterior  fibres  of  the  cardinal  hgament  toward  the 
median  Hne),  are  in  turn  drawn  together  by  inter- 
rupted sutures. 

''After  resecting  a  sufficient  area  of  vaginal  flap 
on  each  side  (the  amount,  if  not  excessive,  is  of  little 
importance),  so  as  to  leave  an  oval  denudation,  the 
mucosa  is  approximated  with  interrupted  silk  sutures. 

''By  following  the  above  directions  closely,  suffi- 
cient fascial  structures  will  be  found  in  almost  every 
case,  especially  in  large  cystoceles  found  in  conjunc- 
tion with  prolapsus. 

"The  fasciae  are  most  often  destroyed  or  lost  by 
operators  who  form  large  vaginal  flaps  or  broadly 
denude,  as  their  first  step  in  cystocele  operations. 
Other  gynecologists  deliberately  cut  through  the 
'pillars'  'in  order  to  free  the  bladder  edges.' 

"The  bladder  can  be  fully  freed  behind  (i.e., 
cephalad)  to  the  'pillars.'  These  structures  are  espe- 
cially valuable,  not  only  because  they  afford  good 
material  for  suture,  but  also  as  they  serve  both  as 
guide  and  tractor  to  the  deeper  parts  of  the  anterior 
portion  of  the  cardinal  ligaments." 

Frank  prefaces  the  above  technique  with  the  claim 
that  it  is  "applicable  to  all  but  very  large  cystoceles, 
that  it  is  always  the  operation  of  choice,  and  only 
to  be  abandoned  if  absence  of  fascial  structures  is 
encountered."  He  concludes  by  stating  that  "in  the 
few  cases  in  which  no  'pillars'  and  no  fascia  can  be 
isolated,  large  cystoceles  may  be  held  back  by  the 
operation  of  vaginal  interposition  (Schauta,  Wert- 
heim),  which  is  simple,  but  the  disadvantages  of 
which  (necessity  for  sterilization,  bladder  symptoms. 


OPERATIONS  FOR  CYSTOCELE. 


179 


Fig.  89. — Extended  operation  for  postclimacteric  cystocele, 
with  complete  procidentia.  {Goffe.)  Vaginal  hysterectomy — 
ligature  of  uterine  artery. 


180  GYNECOPLASTIC   TECHxNOLOGY. 

recurrence  of  protrusion  after  operation  for  pro- 
lapse) have  become  increasingly  apparent." 

It  will  be  recalled  that  the  claim  of  general  effi- 
cacy and  wide  applicability  for  the  procedure  advo- 
cated by  Frank  in  the  cure  of  cystocele  was  likewise 
advanced  with  equal  confidence  for  the  simpler  col- 
porrhaphy.  Moreover,  Frank  vaguely  concedes  that 
"recurrence  must  be  expected  in  i  to  lo  per  cent,  of 
the  cases." 

A  closer  pre-  and  post-operative  scrutiny  of  the 
cases  operated  upon  successfully  by  this  method,  will 
attribute  the  curative  result,  not  to  the  suture  of  the 
suhvesical  fascial  "pillars,"  upon  which  so  much 
stress  is  laid,  but  rather  to  the  elevation  of  the  blad- 
der, the  partial  obliteration  of  the  uterovesical  space, 
and  the  efficacy  of  the  concomitant  perineoplastic 
reconstruction. 

This  operation  is  undoubtedly  beneficial  in  what 
may  be  termed  borderline  conditions,  where  the  pro- 
trusion constitutes  a  maximum  of  colpocele  and  a 
minimum  of  cystocele. 

These  cases  never  present  residual  urine.  The 
floor  of  the  bladder  never  projects  beyond  the  nor- 
mal plane  of  the  vulvar  cleft,  in  addition  to  which 
they  display  one  anatomic  feature  of  almost  pathog- 
nomonic differential  significance  not  heretofore  noted, 
namely,  a  deep  transverse  sulcus  in  the  anterior 
vaginal  wall,  at  the  site  of  junction  between  the 
urethra  and  vesical  neck,  directly  under  the  apex  of 
the  pubic  arch. 

This  transverse  sulcus  is  due  to  the  competence 
of  the  pubovesical  fascia.     It  maintains  the  normal 


t  OPERATIONS  FOR  CYSTOCELE.  181 

direction  of  the  urethra,  and  is  always  obliterated  in 
marked  cystocele. 

The  futility  of  fascial  suture  as  such  in  pelvic 
visceral  support,  and  the  reasons  therefor,  have  been 
fully  discussed  in  the  chapter  on  perineorrhaphy. 
In  addition  to  the  arguments  set  forth  there,  which 
apply  with  equal  force  here,  it  must  be  recalled  that, 
unlike  the  perineal  fasciae,  the  subvesical  fascia  is 
seldom  if  ever  directly  torn.  In  short,  the  normal 
subvesical  fascia  sags,  not  because  of  any  direct  in- 
jury, but  primarily  as  a  result  of  the  levator  tear  in 
the  perineum  plus  uterine  descent,  the  former  de- 
priving it  of  its  fundal  support,  the  latter  carrying 
its  cervical  attachment  downward;  and  it  follow^s  as 
a  logical  corollary  that  the  reefing  of  this  fascia,  more 
especially  in  the  attenuated  condition  encountered  in 
advanced  cases  of  cystocele,  must  prove  illusory  as  an 
element  in  the  restoration  of  permanent  support  to 
the  bladder. 

The  essential  operative  phases  in  the  radical  cure 
of  cystocele  with  uterine  procidentia  demand: — 

I.  Ample  separation  of  the  bladder  base  from  the 
abnormal  uterine  and  vaginal  attachment  acquired  in 
its  descent. 

II.  Correction  of  the  uterine  malposition  by  vagi- 
nal reefing  of  the  round  ligaments. 

III.  Reattachment  of  the  bladder  to  the  anterior 
surface  of  the  uterus  at  the  normal  level  (Goffe). 

IV.  Reconstruction  of  the  musculofascial  support 
in  the  pelvic  floor. 

To  expose  the  base  of  the  bladder,  the  cervix  is 
forcibly  drawn  down  with  a  vulsellum;  its  anterior 
vaginal  coat  is  incised  transversely  just  below  the 


182  GYNECOPLASTIC   TECHNOLOGY. 

level  and  parallel  to  the  lowest  of  the  transverse 
rugae,  which,  in  the  relaxed  state,  invariably  desig- 
nates the  limit  of  the  vaginocervical  attachment  of 
the  bladder. 

From  the  center  of  this  transverse  slit,  a  superfi- 
cial median  longitudinal  incision  is  made,  extending 
for  a  sufficient  distance  upward  toward  the  external 
urinary  meatus,  the  junction  of  the  two  incisions  thus 
forming  an  inverted  T. 

The  mobilization  of  the  bladder  is  begun  at  the 
lower  extremity  of  the  longitudinal  incision  by  sepa- 
rating the  two  central  flap  tips  in  the  angles  of  the 
inverted  T  from  the  underlying  tissues  for  a  distance 
sufficient  to  expose  and  sever  the  cervical  attachment 
to  the  bladder  base,  after  which  the  bladder  is  readily 
brushed  bluntly  from  the  uterus  by  a  gauze-covered 
finger,  up  to  the  vesico-uterine  peritoneal  reflection. 

The  separation  of  the  bladder  from  the  anterior 
vaginal  wall  is  materially  facilitated  by  attention  to 
certain  technical  and  anatomical  details. 

In  picking  up  the  edge  of  the  flap  incision  the 
underlying  tissues  should  be  severed  with  a  few 
strokes  of  the  knife,  so  that  the  T-forceps  grasps  the 
vaginal  tissues  only.  Then  by  gauze  dissection  the 
bladder  is  separated  on  each  side  as  far  out  as  neces- 
sary for  its  free  mobilization. 

The  safety  of  this  rapid  blunt  dissection  lies  in 
rolling  the  yielding  connective  tissue  from  the  raw 
upper  surface  of  the  firm  vaginal  flap  by  the  gauze- 
covered  finger  working  against  counter  pressure  ex- 
ercised by  the  fingers  of  the  opposite  hand  applied  to 
its  under  surface. 

Furthermore,  it  is  essential  to  note  that  there  are 


OPERATIONS  FOR  CVSTOCELE.  183 

two  planes  of  cleavage  between  the  vaginal  mucosa 
and  the  base  of  the  bladder  proper,  separated  by  the 
pubovesical  fascia. 

The  lower  cleavage  plane  lies  between  the  vaginal 
mucosa  and  under  surface  of  the  fascia,  while  the 
upper  separates  the  bladder  from  the  upper  fascial 
surface. 

The  longitudinal  arm  of  the  outlining  flap  incision 
should  penetrate  this  fascia  to  the  upper  plane  of 
cleavage  {i.e.,  between  the  bladder  base  and  upper 
(cephalad)  fascial  surface),  in  which  the  bladder 
may  be  readily  mobilized  without  undue  traumatism 
or  bleeding. 

The  lower  plane  of  cleavage  must  be  avoided,  as 
it  leads  directly  to  the  under  surface  of  the  pubovesi- 
cal fascia,  the  pubic  attachments  of  which  may  offer 
considerable  resistance,  necessitating  their  discission 
in  freeing  the  lateral  aspects  of  the  bladder  wall. 

The  freely  mobilized  bladder  is  elevated  on  a  flat 
speculum  held  against  the  pubic  arch.  This  stretches 
and  exposes  the  uterovesical  fold  of  peritoneum, 
which  is  gently  drawn  down  by  blunt  forceps  and 
grasped  between  the  fingers  like  a  hernial  sac  to  ex- 
clude the  possible  presence  of  omentum  or  intestine, 
after  which  it  is  opened  widely  to  the  base  of  the 
broad  ligament  on  each  side. 

In  stout  patients,  and  in  those  with  deep  pelves,  a 
slight  Trendelenburg  incline  at  this  stage  of  the 
operation  will  facilitate  the  location  of  the  uterovesi- 
cal fold,  and  tend  to  cause  the  intestines  to  gravitate 
from  the  operative  field.  No  gauze  packing  should 
be  used  for  the  latter  purpose. 

Difficulty  is  sometimes  experienced  in  identifying 


184  GYXECOPLASTIC   TECHNOLOGY. 

the  uterovesical  fold.  It  may  be  recognized  by  a  dif- 
ference in  color  from  the  surrounding  tissues,  its 
translucency,  smooth  surface,  and  respiratory  oscil- 
lation. 

In  the  anxiety  to  avoid  injury  to  the  bladder,  con- 
fusion is  sometimes  caused  by  dissecting  too  close  to 
the  uterus.  At  the  cervicovesical  junction,  it  is 
necessary  to  hug  the  cervix  closely,  carefully  brush- 
ing all  loose  tissue  with  the  bladder  wall;  but  once 
the  bladder  wall  begins  to  peel  freely,  and  the  loose 
connective  tissue  between  the  cervix  and  bladder  is 
clearly  defined,  the  remaining  attachment  is  simply 
wiped  off  the  cervix  in  the  line  of  least  resistance, 
which  always  carries  the  separation  direct  to  the 
uterovesical  peritoneum. 

In  the  cure  of  a  complete  procidentia  the  operative 
aim  is  not  only  an  elevation  of  the  prolapsed  organs 
to  their  normal  level,  but  the  equally  essential  restor- 
ation and  maintenance  of  normal  uterine-  poise  by 
vaginal  shortening  of  the  round  ligaments,  which  is 
best  accomplished  b}^  bringing  the  exposed  fundus  to 
the  vulva,  doubling  each  ligament  upon  itself,  and 
sewing  the  loop  to  the  cornual  area  at  the  fundus. 

These  sutures  should  be  inserted  at  the  correct 
distance,  and  in  proper  alignment,  but  not  tied  until 
after  the  fundus  is  replaced  within  the  pelvic  cavity; 
or,  each  ligament  may  be  caught  in  a  chromic  gut 
loop,  introduced  one  inch  from  the  cornua,  the  loose 
strands  of  each  loop  passed  separately  through  the 
respective  vaginal  flap,  one-quarter  of  an  inch  apart, 
and  tied.     (Vaginal  fixation  of  the  round  ligaments.) 

The  fundus  uteri  should  be  brought  to  the  vulva 
by  manipulation   with   a  finger   hooked  behind   one 


OPERATIONS  FOR  CVSTOCELE.  185 

or  other  broad  ligament,  and  n(A  Ijy  traumatizing 
tenacula,  the  dehvery  of  the  fundus  being  facihtated 
by  first  pushing  the  cervix  far  1)ack  into  the  vagina. 

Dr.  J.  Riddle  Goffe  secures  the  elevation  of  the 
bladder  by  suturing  its  base  to  the  anterior  uterine 
wall  as  follows: — 

"Three  chromicized  catgut  ligatures  (No.  2)  are 
passed,  one  through  the  anterior  wall  of  the  uterus 
at  its  midpoint,  and  the  other  two  through  the  an- 
terior walls  of  the  broad  ligaments,  just  outside  the 
lateral  margins  of  the  uterus.  These  are  left  long, 
and  protrude  through  the  vulva.  A  point  is  now 
selected  in  the  base  of  the  bladder,  at  such  a  distance 
from  the  urethra  as,  when  carried  up  to  the  point  of 
insertion  of  the  first  of  these  three  ligatures,  will 
cause  the  base  of  the  bladder  to  make  a  straight  line 
from  the  urethra  to  the  uterus. 

"Through  this  point  in  the  bladder  wall  the  suture 
is  passed,  catching  up  in  its  course  the  bladder  attach- 
ment of  the  peritoneum,  where  it  was  separated  from 
the  uterus.  Two  points  in  the  base  of  the  bladder  are 
now  selected,  at  either  side  of  the  first  selected  point, 
and  distant  from  an  inch  to  an  inch  and  a  half. 
Through  these  points  the  lateral  sutures  are  passed 
respectively.  The  three  are  then  tied,  beginning  with 
the  middle  one.  The  first  takes  up  all  the  slack  in  the 
line  from  the  uterus  to  the  urethra,  but  makes  a  ridge 
in  the  interior  of  the  bladder,  with  a  sulcus  on  either 
side.  By  tying  the  lateral  sutures,  however,  these 
sulci  are  obliterated,  and  the  base  of  the  bladder  is 
spread  out  upon  the  anterior  face  of  the  uterus  and 
broad  ligaments. 

"The  overstretched  fascia  and  hypertrophied  an- 


186  GYXECOPLASTIC   TECHNOLOGY. 

terior  vaginal  wall  are  trimmed  to  fit  snugly  under 
the  bladder  base,  then  sewed  together,  and  to  the 
lower  anterior  surface  of  the  uterus." 

As  an  aid  in  the  identification  of  the  round  liga- 
ments, when  these  are  not  clearly  definable  as  the  re- 
sult of  the  inverted  fundal  position,  three  distinct 
ridges  may  be  noted,  continuous  with  and  extending 
outward  from  the  uterine  cornua.  In  tracing  these 
ridges  backward,  the  anterior  will  be  found  continu- 
ous with  the  round  ligament,  the  middle  with  the  fal- 
lopian tube,  and  the  posterior  with  the  utero-ovarian 
ligament,  the  tubal  ridge  being  the  highest  and  most 
prominent,  the  utero-ovarian  the  lowest  and  posterior. 

When  the  round  ligaments  are  identified,  they  are 
grasped  in  holding  forceps,  and  the  fundus  replaced 
within  the  pelvis.  This  relaxes  the  ligaments,  and 
enables  the  operator  to  estimate  the  necessary  extent 
of  shortening,  and  to  insert  the  sutures,  all  of  which 
is  impossible  with  the  fundus  and  ligaments  on  the 
stretch  at  the  vulvar  outlet. 

There  are  cases  in  w^hich  the  round  ligaments  and 
tubes,  especially  near  their  uterine  extremity,  occupy 
practically  the  same  compartment  in  the  top  of  the 
broad  ligament.  Here  the  looping  and  suture  of  the 
round  ligament  would  necessarily  kink  the  tube  with 
pathological  possibilities.  This  condition  may  be 
recognized  after  reposition  of  the  fundus  by  observ- 
ing the  outlines  of  the  tube  on  pulling  the  round  liga- 
ment loop  before  suturing.  If  tubal  kinking  is  in- 
duced, the  peritoneal  investment  along  the  round 
ligament  should  be  incised  for  a  distance  sufficient  to 
liberate  the  tube. 


OPERATIONS  FOR  CYSTOCELE. 


187 


Fig.  90. — Extended  operation  for  postclimacteric  cystocele, 
with  complete  procidentia.  (Goffe.)  Ligature  of  broad  ligament 
between  the  uterine  and  ovarian  artery. 


188  GYNECOPLASTIC   TECHNOLOGY. 

In  trimming  the  redundant  vaginal  flaps,  there 
is  a  general  tendency  to  remove  too  much  mucosa 
rather  than  too  little,  with  a  consequent  shortening 
of  the  anterior  vaginal  wall.  This  will  tend  to  pull 
the  cervix  toward  the  vulvar  outlet,  and  thus  pro- 
mote the  possibility  of  a  recurrence. 

Vaginal  hysterectomy,  as  a  routine  measure  for 
the  cure  of  complete  procidentia,  cannot  be  too  em- 
phatically condemned.  The  advocacy  of  this  illog- 
ical empiricism  has  been  perpetuated  in  standard 
publications  to  the  present  time.  Thus,  E.  E.  Mont- 
gomery asserts : — 

"Even  in  women  during  the  child-bearing  period, 
any  operation  for  the  successful  retention  of  the  pro- 
truding uterus  and  vagina  is  inconsistent  with  the 
continuance  of  procreation.  No  operative  procedure 
has  been  devised  for  such  a  condition  which  will  suc- 
cessfully endure  the  mechanism  of  a  subsequent  labor. 

"Indeed,  the  changes  produced  in  the  uterus  are 
such  as  to  render  conception  improbable,  and  to  make 
the  uterus  unable  to  develop  in  such  a  way  as  to  oflier 
a  reasonable  probability  that  the  fecundated  ovum 
shall  find  a  proper  soil  and  secure  habitation  to  en- 
sure completion  of  the  pregnancy.  The  uterus  in 
such  cases  is  a  needless  organ — yea,  worse  than 
needless,  a  diseased  organ." 

This  is  fallacious  dogma,  based  upon  premises 
not  substantiated  by  either  clinical,  pathological,  or 
surgical  facts. 

In  the  chapter  on  the  dynamics  of  intrapelvic  vis- 
ceral support,  the  uterus  is  depicted  as  constituting 
a  lever,  with  a  fundal  and  a  cervical  arm,  swung  upon 
a  fulcrum  formed  by  the  projection  of  the  levator 


,  OPERATIONS  FOR  CYSTOCELE.  189 

junction,  which  latter  constitutes  the  "intravaginal 
perineal  crest."  Hence,  to  remove  the  uterus,  or 
ablate  its  cervical  arm,  is  to  remove  an  integral  part 
in  the  mechanism  that  prevents  prolapse  by  deflecting 
the  course  of  intra-abdominal  pressure.  For  the 
same  mechanical  reason,  permanent  fixation  of  either 
uterine  pole  is  contraindicated. 

The  cervix  sJiould  not  he  amputated,  its  bulk  be- 
ing- reduced  to  normal,  when  necessary,  by  the 
method  detailed  in  the  section  on  "Tracheloplasty.'' 

A  prolapsed  uterus  is  a  dislocated  uterus,  and  dis- 
location as  such  is  not  an  indication  for  its  removal, 
notwithstanding  an  existing  menopause.  Further- 
more, hysterectomy  does  not  ensure  the  permanency 
of  the  retention,  as  the  bladder  and  vagina  may  even- 
tually protrude  in  the  absence  of  the  uterus — a  condi- 
tion presenting  an  extremely  doubtful  prognosis  as 
to  the  probability  of  an  ultimate  cure. 

The  indications  for  the  removal  of  the  prolapsed 
uterus  should  be  identical  w-ith  those  in  the  non-pro- 
lapsed organ,  namely,  irremediable  pathologic  alter- 
ation from  chronic  infections  or  neoplasms. 

This  applies  particularly  to  the  aged,  who,  as  a 
matter  of  fact,  suflr'er  more  from  anxiety  than  from 
the  actual  discomfort  induced  by  the  existence  of  the 
prolapse,  both  of  wdiich  may  be  effectually  and  safely 
relieved  by  a  properly  applied  ^lenge  pessary. 

In  the  presence  of  definite  indications,  a  vaginal 
hysterectomy  should  be  performed  by  extending  the 
primary  transverse  incision  on  the  vaginal  mucosa 
completely  around  the  cervix,  severing  the  vaginal 
and  bladder  attachments  of  the  uterus,  which  is  then 
brought  completely  to  the  vulva  and  removed  after 


190 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  91. — Extended  operation  for  postclimacteric  cystocele,  with 
complete  procidentia.  (Goffe.)  The  fundus  uteri  delivered  through 
the  anterior  vaginal  fornix.  Ligature  of  the  utero-ovarian  artery 
and  tube. 


OPERATIOXS  FOR  CYSTOCELE.  191 

clamping  each  broad  ligament  from  top  to  bottom  as 
far  ontward  as  possible,  leaving  or  removing  the 
adnexa  according  to  indications. 

A  continuous  suture  or  chain  ligature  controls 
bleeding  from  the  raw  edges  of  the  broad  ligaments. 

''In  order  to  provide  a  support  for  the  bladder, 
and  also  a  surface  to  act  as  a  deflector  of  intra-ab- 
dominal pressure,  the  broad  ligament  edges  are 
sutured  to  one  another,  from  the  round  ligaments 
down  to  their  bases,  taking  in  sufficient  slack  to  make 
them  draw  taut  across  the  pelvis"  (Goffe). 

"The  bladder  is  spread  out  on  the  anterior  (un- 
der) surface  of  the  broad  ligament  plane  thus  con- 
structed (which  takes  the  place  of  the  uterus),  and 
is  attached  at  three  points  corresponding  to  those 
designated  for  the  cases  with  the  uterus  in  situ,  after 
which  the  pubovesical  fascia  and  trimmed  vaginal 
walls  are  sutured  in  separate  layers,  or  in  bulk" 
(Goffe). 

The  operation  is  completed  by  the  method  of  leva- 
tor myorrhaphy  in  the  pelvic  floor,  as  detailed  in  the 
chapter  on  the  perineum. 

It  is  a  significant  fact,  of  direct  bearing  on  the 
extended  controversy  as  to  the  relative  merits  of  the 
numerous  procidentia  operations  and  their  technical 
variants,  that  none  omit,  and  all  stress,  the  import- 
ance of  an  efficient  pelvic  floor  restoration. 

The  technique,  as  outlined  here,  readjusts  the 
normal  bladder  topography,  obliterates  the  hernial 
pouch  of  the  distended  uterovesical  peritoneum,  aug- 
ments the  resistance  of  this  area  by  superposing  the 
uterine  fundus,  and,  finally,  by  restoring  the  poise 
and  elevation  of  the  uterus  essential  to  its  function 


192 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  92. — The  stumps  of  the  broad  ligaments,  with  their  respec- 
tive ligatures,  seen  in  the  depth  of  the  vaginal  wound.  (Goffe.) 
Introduction  of  broad  ligament  suture  to  form  a  new  base  of  sup- 
port for  the  bladder  in  place  of  the  uterus  removed. 


OPERATIONS  FOR  CYSTOCELE.  193 

as  a  lever  in  the  deflecting"  mechanism,  it  diminishes 
pressure  from  above  the  vesico-uterine  space. 

This  operation  does  not  hazard  the  result  upon  the 
precarious  support  offered  by  the  subvesical  fascia. 
It  creates  no  malinterposition  of  the  bladder,  and  de- 
mands no  sterilization  of  an  otherwise  normal  woman. 

From  a  prognostic  and  technical  point  of  view, 
the  preoperative  differentiation  of  three  types  among 
procidentia  patients  is  essential,  namely: — 

I.  Procidentia  as  an  ultimate  result  of  birth 
trauma  in  previously  normal  women. 

II.  Procidentia  following  birth  injury  in  women 
presenting  the  skeletal  and  static  deviations  pathog- 
nomonic of  congenital  uterine  retroposition.  These 
cases  are  recognized  by  the  sacrolumbar  index  de- 
scribed in  the  chapter  on  retroversion. 

III.  Cases  of  so-called  "virginal  prolapse,"  which 
may  manifest  itself  before  or  after  parity. 

Weinberg  asserts  "that  prolapse  of  the  uterus  in 
the  new-born  and  in  nulliparae  constitutes  3.45  per 
cent,  of  all  cases  of  prolapse.  Nebesky,  in  a  series  of 
232  cases  of  procidentia,  reports  16  as  occurring  in 
nulliparous  women." 

The  majority,  if  not  all,  the  virginal  cases  are  due 
to  the  existence  of  an  unrecognized  Spina  bifida  oc- 
culta, which  involves  the  fourth  sacral  nerves,  with 
consequent  paralysis  of  the  levator  ani. 

The  bony  cleft  of  Spina  bifida  occulta  in  the  lum- 
bosacral region  is  usually  closed  by  a  dense  mem- 
brane; a  characteristic  hairy  patch  may  be  the  only 
local  indication  of  its  existence.  The  cleft  can  usually 
be  felt,  but  in  some  cases  only  the  X-ray  reveals  its 
presence.    The  hair  has  a  typical  concentric  arrange- 

13 


194 


GYNECOPLASTIC   TECHNOLOGY. 


ment  over  the  centre  of  the  defect.  After  puberty  it 
may  grow  to  25  or  30  cm.  in  length,  resembling  a 
tail.  Local  hypertrichosis  is  usual  in  all  SpincB  biMce. 
Cicatricial  changes  in  the  skin  over  the  defect  are 
common,  and  are  always  present  when  tumors  exist 


Fig.  93. — Broad  ligament  stumps  sutured  across  the  midline. 
Suspension  ligatures,  1,  2,  3,  are  passed  from  the  centre  and  sides 
of  the  upper  broad  ligament  border  through  corresponding  points 
at  the  centre  and  sides  of  the  bladder  base,  and  are  drawn  taut. 
(Goffe.) 


within  the  canal.  Lipomata,  fibromata,  myomata, 
angiomata  and  dermoids  are  frequently  found  inside 
or  outside  the  vertebral  canal,  or  occupying  the  bony 

cleft. 


OPERATIONS  FOR  CYSTOCELE. 


195 


Fig.  94. — The  upper  free  end  of  each  suspension  ligament  is 
passed  from  its  insertion  in  the  broaCd  ligament  border  (Fig.  93) 
through  corresponding  points  in  the  subvesical  fascia.  Each  upper 
free  end  is  then  tied  with  its  respective  lower  free  end,  c,  a,  b,  and 
drawn  taut,  bringing  the  base  of  the  bladder  snugly  against  the 
anterior  face  of  the  united  broad  ligaments.     (Goffe.) 


OPERATIONS  FOR  CYSTOCELE.  197 

Discrimination  before  operating  upon  these  cases 
will  obviate  many  difficulties  and  disappointments. 
Let  the  operator  fully  realize  what  he  sets  out  to 
accomplish,  and  he  will  readily  adopt  the  simplest, 
easiest,  and  surest  method  to  this  end.  Let  him,  on 
the  other  hand,  clog  his  mind  with  details  and  special 
plans  of  this  and  that  operator,  and  he  will  follow  an 
uncertain  mixture  of  complicated  and  often  futile 
procedures. 


CHAPTER  XML 

Laceration  Through  the  Anal  Sphinctre. 

One  of  the  most  distressing  phases  of  pelvic  floor 
lacerations  is  fecal  incontinence  from  injury  to  the 
anal  sphinctre. 

In  the  immediate  operation  after  injury,  the  indi- 
cation to  reunite  the  several  tissues  is  plain.  When, 
however,  the  repair  is  to  be  undertaken,  after  healing 
by  granulation  with  subsequent  cicatricial  distortions, 
the  problem  presents  technical  difficulties. 

'■]\Iany  and  varied  methods  are  still  advocated 
that  should,  by  reason  of  general  surgical  advance, 
have  been  discarded,  while  those  appearing  worthy 
of  more  extended  trial  have  not  been  accorded  the 
prominence  they  are  entitled  to"  (C.  G.  Child). 

The  degree  of  sphincteral  incompetence  and  the 
technique  of  the  repair  vary  with  the  extent  of  the 
laceration  into  the  anterior  rectal  wall. 

In  all  cases  of  complete  tear  involving  the  recto- 
A^aginal  septum,  lateral  cicatricial  retraction  shortens 
the  anterior  rectal  wall,  and  buries  the  retracted 
sphinctre  ends  on  either  side  of  the  anus.  In  some 
cases  these  ends  are  caught  in  a  bridge  of  cicatricial 
tissue  spanning  the  anterior  edge  of  the  anal  opening, 
thus  maintaining  a  partial  fecal  control.  But,  as  a 
rule,  the  sphinctre  ends  are  so  widely  separated  as 
to  expose  the  eroded  rectal  mucosa. 

The  technical  dominants  in  the  operative  cure  of 
these  iniuries  comprise  two  objectives: — 
(198j 


LACERATION  TlfROUGlI  THE  ANAL  SPHINCTRE.     199 

I.  Elongation  of  the  shortened  anterior  rectal 
wall  by  utilizing  an  "apron  flap"  of  vaginal  mucosa, 
thus  obviating  the  liability  to  infection  by  suture  of 
the  anterior  rectal  wall  (Warren,  Ristine). 


Fig.  95. — Complete  laceration  of  the  perineum  through  the  anal 
sphinctre.  Rupture  of  the  rectovaginal  septum,  with  retraction  of 
the  anterior  rectal  wall.  Sph,  Sphinctre  pits  over  the  location  of 
the  widely  separated  sphinctre  ends.     (Kelly.) 

II.  Isolation  and  direct  sutural  reunion  of  the 
retracted  sphinctre  ends. 

Laceration  through  the  sphinctre  ani  constitutes 
a  complete  perineal  tear,  and  the  operative  cure  of 


200  GYNECOPLASTIC   TECHNOLOGY. 

the  former  comprises  an  extended  procedure  for  the 
restoration  of  the  latter  in  the  following  order: — 

I.  Outlining  the  area  of  denudation  and  mobili- 
zation of  the  vaginal  "apron  flap"  from  the  recto- 
vaginal septum. 

II.  Liberation  and  isolated  suture  of  the  retracted 
sphinctre  ends. 

III.  Levator  myorrhaphy. 

IV.  Sutural  readjustment  of  the  superficial  peri- 
neal planes. 

With  the  patient  in  the  lithotomy  position,  the 
vulva  is  retracted  laterally  by  tissue-hooks,  inserted 
as  for  incomplete  tear. 

A  transverse  outlining  incision  is  then  carried 
completely  across  the  posterior  vaginal  wall,  one  inch 
to  an  inch  and  a  half  above  its  anal  margin. 

From  each  lateral  extremity  of  this  transverse 
incision  a  longitudinal  incision  is  directed  to  the  pits 
on  either  side  of  the  anus  which  mark  the  location  of 
the  retracted  sphinctre  ends.  The  three  incisions 
thus  outline  a  square  flap  on  the  rectovaginal  septum, 
the  vaginal  layer  of  which  is  carefully  dissected 
downward  to  the  anal  margin  from  the  rectal  layer, 
liberating  an  apron  of  vaginal  mucosa  attached  at 
the  anovaginal  junction. 

The  base  of  this  apron  retracts  into  the  rectum, 
automatically  filling  the  defect  in  its  anterior  wall, 
thus  substituting  a  curtain  of  the  posterior  vaginal 
wall  for  the  deficient  anterior  rectal  wall. 

The  apron  or  flap  is  liberated  from  above  down- 
ward. In  this  way  normal  tissue  is  entered  first,  cica- 
tricial last,  making  the  dissection  easier.  As  the 
proper  line  of  cleavage  between  the  rectal  and  vagi- 


LACERATION  THROUGH  THE  ANAL  SPHINCTRE.    201 

nal  layer  is  entered,  the  splitting  of  the  septum  pro- 
ceeds with  little  difficulty,  until  the  cicatricial  junc- 
ture of  the  vaginal  and  rectal  outlets  is  encountered. 
Here  the  greatest  care  must  be  taken  not  to  button- 
hole  the   apron   or    perforate    the    rectum.      As   the 


Fig.  96. — W'arren-Ristine  operation  for  complete  perineal  lac- 
eration through  the  anal  sphinctre,  with  retraction  of  the  anterior 
rectal  wall.     Outline  of  apron  flap  on  the  posterior  vaginal  wall. 


margin  of  the  septum  consists  of  cicatricial  tissue,  it 
requires  skillful  dissection  to  preserve  a  properly 
nourished  flap. 

After  turning  the  flap  down  over  the  anal  orifice 
like  a  curtain,  the  exposed  tissues  in  the  sphinctre 
pits  are  grasped  and  drawn  forward  by  small  trac- 


202 


GYXECOPLASTIC   TECHNOLOGY. 


tion  forceps,  and  the  retracted  sphinctre  ends  are 
freely  liberated  by  clipping  their  cicatricial  envelope 
with  knife-tip  or  curved  scissors.  When  both  sphinc- 
tre ends  are  freely  mobilized,  they  are  united  by 
interrupted  buried  chromic  gut  or  thin  kangaroo 
sutures. 

After  trimming  the  apron  flap  to  necessary  di- 
mensions,  the  levator  myorrhaphy  and  the   sutural 


Fig.  97. — Child's  outlining  apron  flap  in  the  Warren-Ristine 
operation  for  complete  perineal  laceration.  A,  Sphinctre  pits.  B, 
Upper  extremity  of  outlining  incisions.     C,  Crest  of  the  rectocele. 


readjustment  of  the  superposed  perineal  tissues  is 
carried  out  as  described  under  Perineorrhaphy. 

Sloughing  of  the  apron  edge  sometimes  occurs, 
but  as  a  rule  does  no  harm,  as  the  necrosis  is 
superficial. 

Child  claims  90  per  cent,  of  cures  by  primary 
union  after  the  following  modification  of  this 
method : 


LACERATION  THROUGH  THE  ANAL  SPHINCTRE.    203 

"The  apron  dissected  from  the  posterior  and  lat- 
eral vaginal  walls  is  clamped  at  three  points  and  al- 
lowed to  hang  down  over  the  anus,  where  it  remains 
until  the  completion  of  the  operation.  The  incision  in 
the  vagina  is  closed  with  a  continuous  suture  of  No.  4 


Fig.  98. — Warren-Ristine  operation  for  complete  perineal  lac- 
eration through  the  sphinctre  ani,  with  retraction  of  the  anterior 
rectal  wall.  Suture  through  the  exposed  sphinctre  ends.  Apron 
flap  from  the  posterior  vaginal  mucosa  drawn  over  the  anal  defect 
by  a  tenaculum. 

forty-day  chromic  catgut,  beginning  at  the  apex  of 
the  denuded  area  on  the  posterior  vaginal  wall,  and 
continued  down  to  the  outlet,  thereby  bringing  the 
caruncula  together  in  the  middle  line  to  mark  the 


204  GYNECOPLASTIC   TECHNOLOGY. 

highest  point  on  the  new  perineum,  as  they  originally 
marked  the  highest  point  on  the  old  perineum  before 
it  was  torn, 

"In  uniting  the  muscles  in  the  perineum,  the 
method  that  I  first  described  in  19 13  of  figure-of- 
eight  sutures  of  large-size  silkworm  gut  is  used. 
These  are  introduced  as  follows:  The  first  suture  is 
passed  through  the  ends  of  the  sphinctre  muscle;  the 
free  ends  are  then  crossed  and  introduced  in  the  raw 
area  close  to  the  sheaths  of  the  sphinctre,  and  brought 
out  through  the  skin  on  either  side,  about  one-quarter 
inch  from  the  wound  margin.  These  are  then 
clamped,  but  not  tied.  In  like  manner  three  or  four 
figure-of-eight  silkworm  sutures  are  passed  through 
the  edges  of  the  levator  ani  muscles,  crossed,  and 
made  to  include  in  their  second  bite  all  intervening 
tissue.  A  thorough  irrigation  of  the  wound  area  is 
now  given.  All  blood-clots  that  may  have  formed 
during  the  operation  are  carefully  removed,  and  all 
bleeding  points  tied  with  fine-size  kangaroo  tendon, 

"The  sutures  are  now  tied  in  the  following  man- 
ner :  Beginning  with  the  one  that  unites  the  ends  of 
the  sphinctre,  the  free  ends  are  drawn  on  until  the 
first  bite  of  the  figure-of-eight  is  tightened  sufiiciently 
to  bring  together  the  muscle  ends  within  its  grasp. 
It  is  then  tied  by  a  square  knot,  just  tight  enough  to 
snugly  approximate  the  tissues,  which  it  holds.  The 
remaining  sutures,  uniting  the  levator  muscles,  skin, 
and  subcuticular  tissues,  are  tied  in  the  same  manner, 

"The  sutures  should  never  be  tied  so  tightly  as  to 
cause  cutting  or  strangulation,  and  the  second  knot 
of  each  suture  should  not  be  tied  tight  enough  to 
splinter  the  silkworm,  or  to  interfere  with  untying  it 


LACERATION  THROUGH  THE  ANAL  SPHINCTRE.    205 

later,  should  occasion  arise.  The  wound  is  now  com- 
pletely closed,  and  if  at  its  summit,  the  highest  point 
on  the  perineum,  any  gaping  is  present,  an  extra  silk- 
worm suture  may  be  introduced. 

''A  careful  survey  of  the  field  of  operation  will 


Fig.  99. — Child's  method  of  introducing  figure-of-eight  sutures  in 
the  Warren-Ristine  operation  for  complete  perineal  laceration. 


now  show  that  the  apron  of  Ristine  has  already  to 
some  extent  been  drawn  up  into  the  rectum,  thereby 
lengthening  out  the  previously  shortened  anterior 
rectal  wall,  thus  relieving  all  tension  at  the  anovagi- 
nal  juncture.  A  small  strip  of  iodoform  gauze  is  in- 
troduced into  the  vagina  to  facilitate  drainage  for 
the  first  few  days. 


206 


GYNECOPLASTIC   TECHNOLOGY. 


''The  patient  should  be  catheterized  every  eight 
to  twelve  hours  for  the  first  three  days,  after  which 
the  perineum  is  irrigated  during  micturition.  The 
wound  is  inspected  daily,  and  if  any  of  the  sutures 
have  been  tied  too  tightly  the  tension  should  be  re- 
lieved. The  bowels  are  moved  on  the  third  day, 
castor  oil  being  the  laxative  of  choice,  assisted  by  an 
enema  when  necessary.  If  an  enema  is  given  it 
should  be  under  the  doctor's  supervision,  unless  the 


Fig.   100. — Cross  section  of  figure-of-eight 
sutures   tied.      {Child.) 

nurse  is  thoroughly  familiar  with  this  class  of  cases. 
After  the  third  day,  when  the  vaginal  gauze  is  re- 
moved, a  daily  cleansing  vaginal  douche  of  normal 
saline  is  given.  The  patient  is  kept  in  bed  for  two 
weeks.  After  the  fourth  or  fifth  day  the  apron  of 
tissue  over  the  anus  may  begin  to  slough;  this  will 
have  no  bad  effect  upon  the  healing  of  the  wound,  but 
the  sloughing  area  should  be  clipped  off  with  scissors. 
If  the  line  of  demarcation  is  carefully  followed,  this 
will  cause  no  pain. 


LACERATION  THROUGH  THE  ANAL  SPHINCTRE.    207 

"The  silkworm  .i^ut  sutures  are  removed  between 
the  tenth  day  and  the  end  of  the  second  week.  As  a 
rule,  the  end  of  the  second  week,  when  the  patient  is 
ready  to  get  up  out  of  bed,  is  the  preferable  time. 
Should  infection  occur  in  the  wound,  the  sutures, 
several  or  all,  are  untied  and  loosened,  so  as  to  allow 
of  free  drainage  and  daily  irrigation.  Later,  when 
the  infection  is  over,  and  union  begun,  the  sutures 
are  again  drawn  tight  and  tied,  as  at  the  time  of  their 
introduction.  During  the  third  week  after  operation 
the  patient  is  allowed  up  in  a  chair,  the  bed-pan  is 
discarded,  and  she  may  move  slowly  about  her  room 
each  day." 

Child  concludes:  "So  far  as  I  have  been  able  to 
determine,  the  operations  for  this  condition  per- 
formed by  other  methods  are  far  from  satisfactory, 
yielding  a  very  small  percentage  of  successful  re- 
sults. By  the  Warren-Ristine  technique,  with  certain 
modifications  described,  I  have  reported  the  results  of 
lo  consecutive  cases.  In  only  one  instance  was  vmion 
by  first  intention  in  the  least  interfered  with,  and  in 
90  per  cent,  the  cure  was  absolute.  Once  only,  in 
case  No.  lo,  did  we  fail  to  restore  perfect  control  of 
the  sphinctre  muscle;  yet  as  the  patient's  condition 
was  very  materially  improved,  even  this  case  cannot 
be  classed  as  a  failure." 

In  rare  instances,  the  sphinctre  ani  is  torn  subcu- 
taneously,  causing  fecal  incontinence  without  ex- 
ternal evidence  of  the  lesion.  In  such  cases,  there  is 
also  a  submucous  laceration  of  the  levator  ani,  wnth 
resulting  relaxation  of  the  vaginal  outlet.  j\Iost  fre- 
quently, how^ever,  this  condition  is  due  to  an  unsuc- 
cessful  operation   for   complete  perineal   rupture,   in 


208  GYXECOPLASTIC   TECHNOLOGY. 

which  union  of  the  perineum  is  obtained,  but  with 
failure  to  restore  the  sphinctre  ani. 

To  repair  such  a  sphinctre,  Kelly  makes  a  "horse- 
shoe incision  on  the  perineal  surface,  extending  from 
one  sphincteral  pit  to  the  other,  parallel  to  the  an- 
terior anal  border."  The  flap  of  the  skin  thus  out- 
lined is  turned  down  over  the  anal  opening,  similar 
to  the  apron  flap  described  in  the  preceding  section. 

The  ends  of  the  incision  should  extend  down  on 
either  side  to  expose  the  sphinctre  muscle,  which  is 
readily  palpated  between  index  finger  and  thumb. 

After  liberation  of  the  sphinctre,  its  ends  are 
united  by  two  or  three  interrupted  catgut  sutures. 

It  is  advisable  at  this  juncture  to  introduce  a  re- 
tention stitch  of  silkworm  gut,  transfixing  the  skin 
from  just  behind  the  ends  of  the  incision,  the  sphinc- 
tre ends,  and  the  rectovaginal  septum.  Before  tying 
this  stitch,  the  cutaneous  sutures  are  inserted. 


CHAPTER  XVIIL 

Vesicovaginal  Fistula. 

In  the  entire  evolutional  progress  of  gynecoplastic 
technology  no  single  phase  presents  a  more  striking 
contrast  between  past  and  present  methods  and  re- 
sults than  the  operative  cure  of  vesicovaginal  fistulae. 

In  1663  H.  V.  Roonhuysen  first  suggested  the 
closure  of  such  defects  by  suture.  Following  this 
suggestion,  J.  Fatio  operated  successfully  upon  two 
cases — one  in  1675,  the  other  in  1684 — by  the  method 
published  in  1752:  "With  the  patient  in  the  lithot- 
omy position,  a  speculum  exposed  the  fistula,  the 
edges  of  which  were  freshened  with  a  delicate  pair 
of  scissors,  and  held  in  apposition  by  means  of  a  quill 
suture." 

A.  J.  Jobert  de  Lamballe  (1850-1852)  published 
the  first  elaborate  monograph  on  the  subject,  based 
upon  an  extensive  series  of  operated  cases,  many  of 
them  successful. 

His  method  consisted  in  exposing  the  fistula  by 
speculum  and  traction  on  the  cervix  with  forceps, 
denudation  of  the  fistulous  margin,  and  approxima- 
tion by  suture. 

In  very  extensive  defects,  he  relieved  tension  by 

vaginal  incisions  running  parallel  to  the  edges  of  the 

fistula,  which  permitted  closure  {''par  glissement"). 

An  incision  through  the  vaginal  vault,  detaching  the 

cervix  for  this  purpose,  is  still  known  as  "Jobert's 

incision." 

14  (209) 


210  GYNECOPLASTIC   TECHNOLOGY. 

G.  Simon  (1854)  discarded  the  lateral  vaginal  in- 
cisions of  Jobert,  substituting  tension  sutures  at  a 
distance  from  the  wound.  The  suture  securing  ap- 
proximation of  the  denuded  fistula  margins  he  termed 
''suture  of  union,"  and  the  one  relieving  tension 
"suture  of  detention." 

In  1852,  J.  Marion  Sims,  working  independently 
of  the  above,  devised  the  duck-bill  speculum  and  its 
use  in  the  left  semiprone  (Sim's)  position  of  the 
patient  for  the  better  exposure  of  the  fistula.  He 
bevelled  the  denudation  of  the  fistular  margin,  and 
closed  it  with  silver  wire. 

Sims'  results  in  the  cure  of  vesicovaginal  fistula 
had  not  been  equalled  in  his  time,  but,  notwithstand- 
ing the  brilliant  success  following  upon  his  original 
innovations  and  manual  skill,  there  still  remained  a 
large  class  of  cases  that  proved  intractable  to  prevail- 
ing curative  methods,  and  in  which  surgery  could 
offer  nothing  save  a  complete  occlusion  of  the  vagi- 
nal outlet,  i.e.,  colpocleisis  (Simon). 

The  first  attempts  to  obviate  the  necessity  for  so 
mutilating  a  procedure  were  those  of  Rydygier 
(1887),  and  of  A.  Martin  (1891),  who  planned  to 
cover  the  fistulous  defects  with  pediculated  flaps  from 
contiguous  vaginal  mucosa. 

Trendelenburg  (in  1890)  and  L.  Von  Dittel 
(1893)  departed  radically  from  all  precedent  by  ap- 
proaching the  lesion  through  an  abdominal  incision, 
separating  the  bladder  from  the  uterus,  thus  expos- 
ing and  suturing  the  fistula.  The  suture  included 
only  the  bladder  wall,  and  was  covered  by  the  utero- 
vesical  peritoneum. 


VESICOVAGINAL    FISTULA.  211 

An  epochal  advance  in  the  operative  cure  of  vesi- 
covaginal fistula  was  inaugurated  by  A.  Mackenrodt 
in  1894.  This  consisted  in  the  complete  moljihzation 
of  the  bladder  base  from  its  vaginal  and  uterine  at- 
tachments, and  the  separate  suture  of  the  vesical  and 
vaginal  margins  of  the  fistula. 

In  very  large  defects,  he  interposed  the  uterine 
fundus  to  occlude  the  opening  in  the  bladder  or  vagi- 
nal wall  (vagino-fixation). 

Mackenrodt's  operation  embodies  the  modern 
principle  of  flap  splitting  and  cleavage,  the  practical 
application  of  which  has  brought  the  closure  of  many 
otherwise  intractable  fistulse  of  all  grades,  form,  size, 
and  position,  within  the  range  of  curability,  and  has 
well-nigh  relegated  the  pioneer  work  of  Sims,  Simon, 
and  Emmet,  as  well  as  the  numerous  complex  modifi- 
cations of  their  denudation  methods,  to  the  rear. 

This  method  secures  the  essential  laxity  of  vesi- 
cal structure  in  the  immediate  vicinity  of  the  fistula, 
and  the  free  mobility  of  the  vesical  base,  necessary  to 
effect  permanent  closure  without  incurring  risk  of 
failure  from  undue  tension.  All  subsequent  contri- 
butions present  only  auxiliary  aids  and  modifications, 
adapted  to  isolated  conditions,  that  exercise  no  domi- 
nant influence  on  the  outcome  of  the  procedure  in 
general. 


CHAPTER  XIX. 

Operations  for  Vesicovaginal  Fistula. 

The  anterior  vaginal  wall  is  fixed  and  put  on  the 
stretch  with  two  tenacula,  one  catching  the  cervix 
and  the  other  the  tissues  below  the  external  urinary 
meatus.  A  straight  incision  is  now  made  from  one 
tenaculum  to  the  other,  across  the  fistula,  through  the 
entire  thickness  of  the  vaginal  wall  to  the  connective- 
tissue  layer  separating  it  from  the  bladder. 

Mackenrodt  splits  the  edge  of  the  fistulous 
margin,  cleaves  the  entire  bladder  base  from  its  vagi- 
nal and  uterine  attachments  in  all  directions,  up  to 
the  vesico-uterine  peritoneum  if  necessary. 

The  dissection  is  carred  out  with  knife,  scissors, 
and  gauze  brushing.  Free  mobilization  of  the  blad- 
der, especially  its  base,  is  the  aim.  The  edges  of  the 
bladder  opening  are  trimmed  of  scar  tissue,  and 
brought  together  without  tension  by  a  Lembertizing 
continuous  or  interrupted  mattress  suture  of  fine 
forty-day  chromic  gut,  care  being  taken  not  to  pene- 
trate the  intravesical  surface.  The  vaginal  flaps  are 
finally  pared  and  approximated  by  soft  silkworm 
strands. 

In  general,  it  will  be  found  much  more  expeditious 
to  begin  the  separation  of  the  vaginal  from  the  vesi- 
cal wall  in  the  normal  tissues  at  either  extremity  of 
the  outlining  incision,  i.e.,  below  the  meatus,  or  at 
the  cervical  attachment.  The  normal  line  of  cleavage 
is  readily  located  at  these  points,  from  which  it  is 
(212) 


OPERATIONS  FOR  VESICOVAGINAL  FISTULA.       213 

easily  extended  on  all  sides  toward  the  cicatrized 
margins  of  the  fistula,  the  mobilization  and  splitting 
of  which  is  thus  facilitated. 

In  very  extensive  tissue  defects,  the  uterine  fun- 


Fig.  lOL — Closure  of  bladder  fistula  with  buried  catgut  sutures, 
without  penetrating  the  vesical  mucosa.     (Mackenrodt.) 

dus  is  interposed  between  the  bladder  and  vagina,  its 
posterior  surface  thus  filling  the  bladder  gap,  while 
its  anterior  bridges  the  vaginal  opening. 

In     'Vesico-uterine"     and     "vesico-uterovaginal" 
fistulse,  the  application  of  Mackenrodt's  principle — 


214 


GYNECOPLASTIC   TECHNOLOGY. 


namely,  isolation  and  separate  suture  of  the  vesical, 
uterine,  and  vaginal  tissues — offers  the  most  certain 
means  to  successful  repair. 

Only  in  those  cases,  fortunately  rare,  in  which  a 


Fig.  102. — Vesicovaginal  fistula.     Mackenrodt's  operation. 
Approximation  of  vaginal  flap. 


vesico-uterovaginal  fistula  is  complicated  by  very  ex- 
tensive intrapelvic  disease,  with  firm  fixation  at  the 
vaginal  vault,  does  an  attack  by  the  abdominal  route 
with  possible  hysterectomy  for  access  to  the  fistulous 
tract  come  under  consideration. 


OPERATIONS  FOR  VESICOVAGINAL  FISTULA.       215 

U refer ovaginal  fistula  should  be  operated  intra- 
abdominally,  as  a  rule.  Vaginal  plastic  efforts  to  im- 
plant the  ureter  end  or  the  fistulous  tract  into  the 
bladder,  converting  the  ureterovaginal  into  a  uretero- 
vesical fistula,  are  not  to  be  commended,  as  a  prob- 
able stenotic  contraction  at  the  site  of  union  invari- 
ably eventuates  in  destructive  degeneration  of  the 
corresponding  kidney. 

In  ureterovesicovaginal  fistula,  the  simplest  and 
surest  course  is  to  implant  the  ureter  into  the  bladder 
by  the  abdominal  route,  and  repair  the  vesical  open- 
ing through  the  vagina. 

Exceptionally  favorable  cases  of  this  class,  in 
which  the  ureteral  and  vesical  openings  are  small, 
very  close  to  one  another  and  imbedded  in  lax,  acces- 
sible surroundings,  may  be  operated  entirely  by  the 
vaginal  route  in  one  of  several  ways. 

An  oval  denudation,  at  least  one-third  of  an  inch 
wide,  is  made  to  encircle,  like  a  ring,  a  small  island 
of  vaginal  mucosa,  the  centre  of  which  presents  the 
fistulous  openings  of  ureter  and  bladder.  The  marg- 
ins of  the  denuded  circle  are  united  by  suture  in  the 
line  of  least  resistance,  thus  turning  the  ureteral  ori- 
fice into  the  bladder  (Schede). 

Where  the  ureteral  orifice  is  readily  located,  it 
may  be  split  on  its  vesical  aspect  to  the  extent  of  half 
an  inch,  making  its  opening  continuous  with  that  in 
the  bladder.  The  object  in  either  of  the  above  proce- 
dures is  to  eliminate  the  ureteral  opening  as  a  compli- 
cating factor,  and  reduce  the  condition  to  one  of 
simple  vesicovaginal  fistula. 

Sampson,  in  a  study  of  158  total  hysterectomies 
for  carcinoma,  performed  at  Johns  Hopkins,  records 


216  GYNECOPLASTIC   TECHNOLOGY. 

19  cases,  or  12  per  cent.,  of  bladder  injuries  with 
resulting  fistulse. 

These  fistulse  usually  present  a  small  opening, 
which  is  buried  in  the  rigid,  firmly  adherent  vault  of 
an  atrophied  and  contracted  vagina. 

Every  fistulous  defect  of  the  bladder,  that  is 
freely  and  completely  mobilized  from  its  vaginal  and 
uterine  attachments,  and  properly  sutured  without 
tension,  will  heal  promptly. 

The  technical  difficulty  presented  by  postoperative 
vesicovaginal  fistulse  is  their  inaccessibility. 

To  overcome  this  difficulty,  Kelly  incises  the  pos- 
terior vaginal  fornix  at  the  site  of  the  cul-de-sac,  and 
opens  the  peritoneal  cavity.  This  tends  to  lower  and 
partially  liberate  the  plane  of  the  fistulous  area,  which 
may  thus  be  drawn  down  within  reach.  But  an  aid 
of  wider  scope,  affording  much  greater  accessibility, 
is  offered  by  the  paravaginal  incision  devised  by 
Schuchardt,  to  which  Ward  redirected  attention  in 
the  following: — 

'Tt  is  rather  strange  that  in  America  a  correct 
conception  of  this  incision,  and  appreciation  of  its 
value,  is  rare.  In  the  minds  of  many  operators  con- 
fusion exists  between  Schuchardt's  incision  and  the 
ordinary  lateral  vaginoperineal  incision,  which  is 
similar  to  a  simple  episiotomy.  The  two  incisions  are 
totally  different,  and  there  is  no  comparison  as  to 
their  effectiveness  in  procuring  accessibility. 

The  simple  straight  vaginoperineal  incision  is 
superficial,  and  much  less  extensive,  as  compared  to 
Schuchardt's.  Its  length  is  limited  by  the  pelvic  wall, 
and  it  is  usually  necessary  to  make  one  on  each  side 
of  the  perineum. 


OPEkATlOXS  FOR  VESICOVAGINAL  FISTULA.        217 


'^JLi^^RmhI 

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^^m 

■_{ 

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^ 

^^^^r 

ttyj 

^^^^^^^^Hs  .  '^  1 W 

1X9 

^Bm^^^ks^^^^^HPsT^  I 

a^l^H 

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'i^^^^wi^^ 

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'i^l^H^^^HHK 

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■■  '^*::'y -t'.;  ">'"i^^^^^^BBhteis 

5. 

Fig.  103. — Lateral  vaginoperineal  incision  as  made  by 
Duehrrsen  and  others.     (Ward.) 


218  GYNECOPLASTIC   TECHNOLOGY. 

Schuchardt  first  described  his  incision  in  1893  for 
the  radical  vaginal  extirpation  of  the  carcinomatous 
uterus,  and  Schauta  and  others  have  adopted  it  in 
their  vaginal  operations  for  cancer. 

In  1896  he  advocated  its  employment  for  other 
conditions  besides  carcinoma  of  the  uterus,  and  re- 
ported a  case  of  its  successful  use  in  rendering  acces- 
sible a  double  vesicovaginal  fistula  which  was  fixed 
in  scar  tissue  high  in  the  vagina.  In  1901  he  con- 
tributed a  further  study  of  his  incision,  with  an 
anatomical  report  by  Waldeyer. 

Vaginoperineal  incisions  have  been  employed  by 
many  operators  prior  to  Schuchardt's  description  of 
his  operation  in  1893,  notably  Duehrrsen,  Leopold, 
Chaput,  Picque,  and  others ;  but,  as  Sinclair  remarks, 
it  is  not  fair  to  speak  of  Schuchardt's  method  as  a 
mere  extension  of  these  incisions;  it  is  a  distinctly 
beneficial  addition  to  the  resources  of  operative  gyne- 
cology. Sinclair  made  Schuchardt's  incision  on  the 
cadaver,  and  had  the  anatomical  relations  studied  by 
Young. 

Gellhorn  says:  'The  effect  of  the  paravaginal 
incision  is  surprising.  In  place  of  a  vaginal  tube  we 
have  before  us  a  shallow  excavation  not  deeper  than 
one  inch." 

Duehrrsen  claimed  that  he  had  recommended  the 
same  incision  three  years  prior  to  Schuchardt,  but  a 
study  of  his  paper  shows  that  he  described  the 
straight  vaginoperineal  incision,  which  is  directed  to- 
ward the  ischium,  and  is  but  2  to  3  centimeters  in 
depth. 

In  1892  Chaput  described  an  incision  similar  to 
that  of  Duehrrsen,  before  the  Congres  Frangais  de 


OPERATIONS  FOR  VESICOVAGINAL  FISTULA.        219 


Fig.  104. — Schuchardt's  incision  outlined.     (IVard.) 


220  GYNECOPLASTIC   TECHNOLOGY. 

Chirurgie,  which  he  designated  as  a  ''colpoperineoto- 
mie  laterale,"  and  in  the  discussion  Picque  stated  he 
had  utihzed  it  several  times  for  high  vesicovaginal 
fistulse. 

The  vaginoperineal  incision  of  Duehrrsen,  as  de- 
scribed by  him  in  1889,  commenced  6  to  7  centimeters 
within  the  vagina,  at  the  junction  of  the  posterior 
with  the  lateral  wall,  and  extends  in  a  straight  line 
for  a  similar  distance  on  the  skin  toward  the  ischium. 

Schuchardt,  in  his  later  description  of  his  opera- 
tion, describes  the  site  of  the  incision  as  a  triangle, 
one  side  of  which  is  on  the  vaginal  wall,  the  other  on 
the  skin  from  the  junction  of  the  middle  and  lower 
third  of  the  labia  majora  to  a  point  a  finger's  breadth 
posterior  to  the  anus,  near  the  middle  line,  and  the 
base  forms  a  line  extending  obliquely  from  the  upper 
end  of  the  incision  on  the  vagina  to  a  point  just  pos- 
terior to  the  anus.  It  lies  from  within  outward,  partly 
in  paravaginal  and  in  pararectal  tissue,  the  fat  of  the 
ischiorectal  fossa,  and  in  the  subcutaneous  tissue. 
The  surface  of  this  triangle  is  curved  on  its  long  axis, 
with  its  concavity  toward  the  rectum. 

The  incision  is  made  preferably  on  the  left  side, 
as  it  is  easier  for  right-handed  operators.  The  left 
labium  is  put  on  the  stretch,  and  is  divided  at  the 
junction  of  its  middle  and  posterior  third.  The  in- 
cision is  then  extended  up  the  whole  length  of  the 
vaginal  tube  at  the  junction  of  the  posterior  and 
lateral  walls,  completely  splitting  the  vaginal  canal. 
It  is  next  continued  on  the  cutaneous  surface  in  a 
curve  outside  of  and  encircling  the  sphinctre  ani,  the 
integrity  of  which  is  preserved,  and  terminates  a 
finger's  breadth  posterior  to  the  anus  near  the  median 


OPERATIONS  FOR  VESICOVAGINAL  FISTULA.        221 


,     LEVATOR 


\    y\Ni 


r^ECTUMDl^AWN 
TO  ONE  SIDE 


Fig.  105. — Schuchardt's  incision  completed. 
(Drawn  from  life,  Ward.) 


222  GYNECOPLASTIC    TECHNOLOGY. 

line.  The  entire  incision  is  then  deepened  in  a  curved 
direction,  enveloping  the  rectum,  without  injuring  it, 
until  the  inner  surface  of  the  canal  of  the  levator  ani 
and  coccygeus  muscle  and  the  depths  of  the  ischio- 
rectal fossa  are  plainly  exposed.  If  the  incision  has 
been  correctly  made — that  is,  with  a  sufficient  curve 
— the  levator  muscle  will  not  be  cut,  except  the  super- 
ficial fibres  near  their  insertion  into  the  coccyx  and 
sphinctre  ani. 

It  will  then  be  seen  that  the  incision,  while  com- 
mencing laterally  on  the  vaginal  surface,  terminates 
at  its  base  near  the  median  line,  posterior  to  the  rec- 
tum, encircling  that  organ,  and  consequently  mobiliz- 
ing it,  so  that  it  may  be  displaced  to  one  side.  Thus 
the  incision,  for  all  practical  purposes,  becomes  a 
median  one,  lying  in  the  longest  diameter  of  the  pelvic 
outlet,  thereby  obtaining  the  maximum  amount  of 
space.  The  incision  divides  the  whole  vaginal  canal, 
the  labium,  the  skin  of  the  perineum  and  lateral  anal 
region  down  to  the  coccyx,  the  superficial  fascia,  the 
bulbocavernosus  and  transversus  perinei  muscles,  the 
lower  part  of  the  triangular  ligament,  the  paravagi- 
nal and  pararectal  tissues,  the  outer  fibres  of  the 
levator  ani  near  their  sphinctre  ani  and  coccygeal 
attachment,  and  the  cellular  tissue  of  the  ischiorectal 
fossa.  It  passes  below  the  vestibular  bulb  and  Bar- 
tholin's gland. 

Only  the  superficial  branches  of  the  perineal  and 
inferior  hemorrhoidal  vessels  and  nerves  are  divided, 
and  hemorrhage  is  readily  controlled  with  a  few 
ligatures. 

In  spite  of  the  extent  of  the  incision,  no  tissue  of 
importance  is  injured,  and  the  wound  unites  readily 


OPERATIONS  FOR  VESICOVAGINAL  FISTULA.        223 

if  closed  with  a  layer  of  buried  and  external  sutures. 
A  rubber  tissue  drain  should  be  placed  at  the  lower 
angle  of  the  incision,  extending  into  the  ischiorectal 
fossa. 

The  wide  separation  of  the  bladder  from  the  va- 
gina is  practically  that  of  the  modern  operation  for 


Fig.  106. — Geometrical  figure  of  the  plane  of 
Schuchardt's  incision.     (IVard.) 


cystocele,  with  a  more  extensive  dissection  at  the 
vaginal  vault.  In  cases  in  which  the  bladder  is  ex- 
tensively adherent  to  dense  cicatricial  tissue,  a  trans- 
verse incision  extending  the  full  width  of  the  vault 
is  essential  in  order  to  free  it  sufficiently. 

I  would  not  hesitate  to  freely  open  the  peritoneal 
cavity,  as  recommended  by  Kelly,  but  so  far  I  have 
not  found  it  necessary.     It  is  wise  to  bear  in  mind 


224 


GYXECOPLASTIC    TECHNOLOGY. 


the  possibility  of  the  proximity  of  an  adherent  loop 
of  intestine  where  the  uterus  has  been  removed. 

The  point  in  the  technique  which  I  wish  to  empha- 
size is,  that  in  separating  the  bladder  base  from  the 
vagina  the  dissection  should  commence  at  the  outer 


^^ 

M 

^ 

■i 

fe 

|E  J™" 

I^H 

HH^I 

^B 

^^^HBlrf^    1  ft 

■ 

1 

^H 

BBBg*    ''^-y 

i 

1 

^H 

^^^^1    ' 

i 

% 

-? 

^^^^1^^^^ 

pp^ 

ipV' ' 

■■Jl^ 

--<«[ 

^^^^HP^ 

Fig.  107. — Commencement  of  mobilization 
of  the  bladder.     {Ward.) 


end  of  the  anteroposterior  incision  near  the  meatus 
urinaris,  where  there  is  an  absence  of  scar  tissue,  and 
where  it  is  a  simple  matter  to  find  the  line  of  cleavage 
between  the  bladder  wall  and  the  vagina.  This  having 
been  established,  the  separation  is  carried  upward  and 
outward  until  the  cicatricial  tissue  in  the  region  of 


OPERATIONS  FOR  VESICOVAGINAL  FISTULA.        225 

the  fistula  is  encountered,  when  the  dissection  pro- 
gresses, partly  Ijy  the  use  of  the  gauze-covered  finger, 
and  partly  by  snipping  with  round-pointed  scissors, 
with  a  fair  degree  of  safety,  by  reason  of  the  line  of 
cleavage  having  been  first  determined,  and  by  the  use 
of  a  sound  in  the  bladder  as  a  guide. 

If  care  and  patience  are  exercised  in  freeing  the 
bladder  laterally  to  the  utmost  limit,  not  only  at  the 
vault,  but  also  throughout  the  length  of  the  anterior 
vaginal  wall,  the  next  procedure  (that  of  dislocating 
the  bladder  wall  downward  so  as  to  bring  the  site  of 
the  fistula  wathin  easy  reach)  will  be  greatly  facili- 
tated. 

The  employment  of  an  instrument  introduced  into 
the  bladder  through  the  urethra  for  this  purpose,  and 
to  act,  as  a  counterpoint,  has  been  advocated  by  Pas- 
teau,  of  France.  He  has  devised  a  special  instrument 
for  the  purpose,  but  I  can  see  little  advantage  in  it 
over  a  sound. 

I  consider  that  the  employment  of  an  instrument 
in  the  bladder,  used  as  a  lever  and  counterpoint,  is  a 
decided  aid,  and  I  have  found  a  straight  male  sound 
(No.  28,  French  scale)  to  be  most  satisfactory  for 
this  purpose. 

Catgut  should  be  used  for  closing  the  opening  in 
the  bladder  wall.  I  have  found  No.  i.  chromic  gut 
suitable  for  this  purpose.  The  needles  should  be  very 
short,  curved,  round-pointed,  and  strong.  These 
sutures  should  penetrate  the  muscular  coat  of  the 
bladder  only,  and  have  the  effect  of  turning  in  the 
edges  of  the  fistula.  A  second  layer  may  be  used  to 
advantage  in  some  cases. 

The  vaginal  incision  at  the  vault  should  be  closed 

15 


226 


GYNECOPLASTIC    TECHNOLOGY. 


with  silkworm  gut  sutures,  an  important  point  being 
to  catch  with  each  stitch  the  base  of  the  bladder  to 
one  side  and  beyond  the  fistula,  so  that  when  tied  the 
lines  of  suturing  will  be  brought  in  different  planes, 
and  will  avoid  dead  spaces. 


Fig.  108. — Displacement  downward  of  the  bladder  by  means  of  a 
sound.    Sutures  embracing  fistular  margins  in  place.  (Ward.) 

The  bladder  should  be  drained  with  a  self-retain- 
ing catheter,  or  be  frequently  catheterized  for  a 
period  of  six  days. 

Nothing  serves  more  to  signalize  gynecoplastic 
progress  during  the  past  fifty  years,  than  the  state- 


OPERATIONS  FOR  VESICOVAGINAL  FISTULA.        227 

nient,  llial,  not  one  of  the  indications  postulated  by 
Simon  for  colpocleisis,  with  its  morl)id  sequella,  is 
vaHd  at  the  present  time.  No  case  of  vesicovaginal 
fistula,  whatever  its  extent,  should  be  considered 
hopeless  from  a  reparative  standpoint,  provided  the 
vesical  sphinctre  and  adjacent  portions  of  the  ure- 
thra are  intact.  Surgery  can  repair,  but  cannot 
create,  a  sphinctre  muscle. 

To  restore  a  sphinctre  that  is  partly  lacerated  or 
completely  severed,  as  after  pubotomy,  the  bladder 
should  be  completely  liberated,  as  for  vesicovaginal 
fistula.  The  urethra  and  bladder  are  then  sutured 
over  a  rubber  catheter  with  interrupted  sutures  of 
chromic  gut,  which  grasp  the  muscular  but  not  the 
mucous  coat. 

At  the  bladder  neck,  the  sphinctre  fibres,  together 
with  a  delicate  but  distinct  fascia,  are  caught  in  the 
sutures,  or  sewn  separately,  just  as  the  sphinctre  ani 
is  reunited  in  complete  perineal  tears. 

The  torn  and  retracted  sphinctre  ends  must  be 
sought  and  isolated  close  to  the  edges  of  the  pubic 
rami.  As  an  aid  in  locating  these  fibres,  Frank  sug- 
gests ''passing  a  traction  suture  about  i  centimeter 
from  the  pubic  ramus,  at  the  level  of  the  vesical  neck ; 
when  this  traction  suture  is  pulled  upon,  the  stronger 
and  deeper  fibres  are  broug-ht  into  view." 

Whenever  the  vesical  sphinctre  has  been  com- 
pletely destroyed  in  consequence  of  excessive  trauma 
and  sloughing  no  effort  should  be  expended  in  plastic 
attempts  to  restore  the  urethral  canal,  which  can  at 
best  yield  but  a  cosmetic  result,  not  urinary  contin- 
ence. The  only  feasible  expedient  in  this  lamentable 
and    otherwise    intractable    condition    is    the    direct 


228 


GYNECOPLASTIC   TECHNOLOGY. 


Fig.  109. — Vaginal  sutures  in  situ.     (Ward.) 


OPERATIONS  J'OK  VIiSICOVAGINAL  I-ISTULA. 


229 


drainaj^-e  of  the  Ijladder  into  the  rectum  by  establish- 
ing" an  ample  communication  between  the  bladder  and 
rectum  via  the  vagina.  This  secures  a  tolerable 
urinary  continence  by  means  of  the  anal  sphinctre. 

While   this   exj)edient   may   a])])ear   objectionable 
on  theoretical  grounds,  its  practical  utility  has  been 


Fig.  110. — Exposure  and  suture  of  (lacerated)  sphinctre  vesicae. 
Vaginal  flaps  (F)  have  been  liberated  and  retracted.  The  bladder 
(Bl)  has  been  freed  and  pushed  upward,  exposing  the  supra- 
vaginal part  of  the  cervix  (C).  On  each  side  the  pubocervical  liga- 
ments (P-C)  have  been  exposed.  The  sphinctre  fibres  are  shown 
partly  approximated  by  traction  on  two  untied  sutures.     (Frank.) 


amply  demonstrated  by  clinical  and  experimental  re- 
sults, which  tend  to  prove  that  the  rectum  can  be 
used  as  a  substitute  for  the  urinary  bladder  without 
giving  rise  to  rectal  irritation. 

Peterson,  in  a  recent  article  entitled,  "Substitu- 
tion of  the  Anal  for  the  Vesical  Sphinctre  in  Certain 
Cases  of  Inoperable  Vesicovaginal  Fistul?e",  which 
embraces  the  entire  literature  of  the  subject  to  date. 


230  GYNECOPLASTIC    TECHNOLOGY. 

States:  "According  to  Lipinsky,  the  first  utilization 
of  the  rectal  sphinctre  for  the  control  of  the  urine 
after  the  formation  of  a  vesicovaginalrectal  fistula 
and  closure  of  the  vagina  (colpocleisis)  or  the  vulva 
(episiocleisis)  is  to  be  credited  to  Maisonneuve.  .  .  . 
The  operation  had  been  suggested,  but  not  practised, 
by  Jobert  in  1836,  and  Berard  in  1845." 

Commenting  upon  41  recorded  cases,  inclusive  of 
his  own,  Peterson  concludes:  "Most  of  the  opera- 
tions were  performed  for  conditions  where  restora- 
tion of  function — i.e.,  urinary  continence — was  hope- 
less from  the  start,  because  of  loss  of  the  vesicle 
sphinctre.  In  a  way,  every  case  of  the  operation  we 
are  considering  is  a  confession  of  failure.  It  is  not, 
and  never  will  be,  an  ideal  procedure.  At  the  most, 
it  is  merely  a  way  out  of  a  serious  difficulty." 

As  the  peritoneal  cavity  is  not  invaded  by  this 
operation,  there  should  be  no  primary  mortality. 

This  is  borne  out  by  Peterson's  study.  Maison- 
neuve's  case  in  185 1  died  directly  from  the  operation, 
but  as  a  result  of  septic  phlebitis.  Morisani  lost  one 
patient,  on  the  eighteenth  day,  from  pneumonia.  One 
of  Rose's  patients  died  ten  months  after  the  opera- 
tion from  nephritis,  while  another  operated  upon  for 
malignant  disease  died  nine  weeks  later  from  metas- 
tatic occlusion  of  both  ureters. 

Among  the  successful  cases,  urinary  control  was 
maintained  for  from  one  to  eight  hours. 

In  12  cases,  the  women  menstruated  through  the 
rectum  without  apparent  inconvenience,  while  9  pa- 
tients ceased  to  menstruate  after  the  operation  with- 
out obvious  cause.  Infection  of  the  uterine  cavity 
from  contiguity  of  rectal  contents  was  not  observed. 


OPERATIOXS  FOR  VESICOVAGINAL  FISTULA.       231 

The  most  important  fact  established  by  these 
cases  is,  that  ascending  renal  infection  was  absolutely 
excluded,  which  is  undoubtedly  due  to  the  preserva- 
tion of  the  normal  ureteral  orifices  and  ample  drain- 
age at  the  lowest  point  of  the  bladder  base. 

In  performing  the  operation  for  the  establishment 
of  a  permanent  vesicovaginorectal  fistula,  it  is  essen- 
tial to  bear  in  mind,  that  the  vesical  and  rectal  open- 
ings must  be  made  large  enough  to  allow  for  post- 
operative contraction,  which  occurred  in  9  out  of  the 
41  recorded  cases. 

The  rectal  opening  should  be  made  just  above  the 
internal  sphinctre  muscle,  large  enough  to  admit  two 
fingers. 

The  edge  of  each  fistulous  opening  should  be 
whipped  over  by  a  running  suture,  but  the  two  fistu- 
lous openings  should  not  be  anastomosed. 

It  will  obviate  the  tendency  to  cicatricial  recon- 
traction  to  excise  an  ellipse  from  the  anterior  and 
posterior  vaginal  mucosa,  and  simply  incise  the  un- 
derlying bladder  base  and  rectal  wall  longitudinally 
for  i^  to  2  inches.  The  hemming  of  the  fistulous 
edges  thus  advantageously  everts  the  vesical  and 
rectal  mucosa,  which  acts  as  a  valvular  curtain,  pre- 
venting the  regurgitation  of  feces  into  the  bladder. 

In  15  of  the  reported  cases,  the  operation  w^as 
performed  in  two  stages,  the  fistulae,  vesical,  and 
rectal  being  made  first,  and  the  vulva  subsequently 
closed.  In  the  majority  of  the  cases,  however,  the 
operation  may  be  completed  in  one  sitting. 

The  closure  of  the  vagina  (colpocleisis-episioclei- 
sis)  is  performed  by  removing  a  wide  collar  of  tissue 


232  GYNECOPLASTIC   TECHNOLOGY. 

from  the  circumference  of  the  vulvovaginal  outlet, 
and  uniting  the  denuded  surfaces  with  interrupted 
silkworm  sutures.  This  converts  the  perforated  blad- 
der and  vagina  into  a  common  reservoir  for  urine 
and  menstrual  blood,  which  drains  through  the  recto- 
vaginal fistula  into  the  rectum,  from  which  it  is  dis- 
charged at  intervals  through  the  anus.  The  urethral 
canal  should  either  be  extirpated  in  denuding  the 
vulvovaginal  outlet,  or  its  canal  obliterated  by  a 
Paquelin  cautery. 

It  is  difficult  to  secure  a  primary  union  of  the  en- 
tire vulvar  cleft.  In  only  two  instances  of  the  series 
reported  by  Peterson  was  this  attained.  The  small 
resulting  fistulse,  however,  heal  very  readily  on  the 
application  of  caustics,  only  6  of  the  41  recorded 
cases  having  proved  intractable. 

As  already  indicated,  this  operation  has  no  direct 
mortality;  there  is  no  danger  of  renal  infection;  there 
is  no  regurgitation  of  feces  into  the  vagina;  there  is 
no  irritation  of  the  rectum.  It  precludes  copulation, 
which,  however,  is  equally  interdicted  by  the  eroded 
tissues  and  vaginal  defects  in  the  unoperated  con- 
dition. 

It  is  a  mutilation  of  the  genitals,  but  it  substitutes 
a  very  tolerable  state  for  an  intolerable  condition. 

Keen,  the  first  among  American  surgeons  to  ap- 
ply this  procedure  in  a  case  resulting  from  typhoid 
sloughing,  comments  upon  the  result  as  follows: 
"It  is  an  encouraging  fact  that  in  any  case  requiring 
similar  treatment,  the  later  history  of  the  patient 
shows  that  for  twenty-one  years  she  has  only  twice 
had  the  least  trouble — once  from  a  small  calculus 
forming  in  the  vagina,  and  once  from  a  small  abscess 


OPKRATIOXS  V()\i  VESICOVAGINAL  FISTULA.       233 

forming  in  the  cicatrix,  which  abscess  spontaneously 
closed.  Instead  of  being  a  constant  source  of  disgust 
to  herself  and  everybody  about  her,  a  hospital  patient 
dependent  upon  charity,  and  a  pariah,  cut  off  from 
all  society,  she  has  been  enabled  to  become  self-sup- 
porting as  a  nurse,  and  to  enter  freely  into  her 
wonted  social  relations." 


CHAPTER  XX. 

Functional  Urinary  Incontinence. 

There  is  a  class  of  climateric  multiparse,  with  a 
record  of  difficult  and  prolonged  labors,  who  suffer 
from  a   relaxed   and   incompetent  vesical   sphinctre. 

Their  involuntary  urinary  discharge  varies  from 
an  occasional  ejection  on  coughing  or  other  sudden 
exertion  to  a  constant  dribble. 

In  the  surgical  correction  of  this  condition,  vari- 
ous urethroplastic  operations  are  advocated,  namely, 
narrowing,  lengthening,  twisting,  or  displacement  of 
the  urethral  tube,  all  of  which  can  at  best  only  miti- 
gate the  incontinence  by  establishing  an  artificial  im- 
pediment to  the  urinary  escape  in  the  place  of  its 
sphincteral  control. 

The  rational  operative  indication  in  urinary  in- 
continence, due  to  widening  of  the  sphincteral  open- 
ing from  relaxation,  is  to  contract  such  openmg  by 
sutural  furling  of  its  muscular  ring  at  the  vesical 
neck  in  the  following  manner: — 

The  anterior  vaginal  wall  is  divided  by  a  median 
longitudinal  incision  extending  well  over  the  pos- 
terior part  of  the  urethra  and  vesical  neck.  The 
vaginal  flap  on  each  side  is  caught  by  forceps-  and 
separated  from  the  underlying  tissues  for  an  ample 
distance  outward. 

The  vesical  sphinctre  should  be  accurately  located 
by  a  bulbous  sound,  which  is  passed  into  the  bladder 
and  withdrawn  until  its  head  engages  in  the  vesical 
(234) 


FUNCTIONAL  URINARY  INCONTINENCE. 


235 


neck.      "Jlic   sphinctre   tlicn   lies   just   in    front   of  the 
bulb,  which  is  identified  ])y  ])ali)<'ilion. 

The  muscle  may  now  be  exposed  by  deeper  dis- 
section, and  furled  by  direct  suture;  or  the  sphinc- 
teral openin,"'  may  he  narrowed  indirectly  by  the  in- 


Fig.  111. — Operation  for  functional  incontinence  of  urine,  due 
to  relaxed  sphinctre.  The  vaginal  mucosa  has  been  reflected  ex- 
posing the  sphinctre  area  and  the  course  of  the  constricting  sutures. 

folding"  of  its  enveloping  tissues  with  mattress  sutures 
of  silk  or  linen  thread,  after  the  method  suggested  by 
Kelly,  as  shown  in  the  illustration. 

The  mattress  suture,  when  correctly  placed,  em- 
braces the  region  of  the  sphinctre  muscle,  narrows  its 


236 


GYXECOPLASTIC    TECHXOLOGY. 


Opening,  elevates  the  vesical  neck,  and  restores  the 
essential  angle  of  the  urethrovesical  junction.  The 
vaginal  wall  is  finally  reunited  in  its  normal  relations. 
In  the  majority  of  cases  a  relaxed  vesical  sphinc- 
tre  is  part  and  parcel  of  a  generally  relaxed  pelvic 


Pig.  112. — Operation  for  urinary  incontinence  due  to  relaxed 
vesical  sphinctre.  The  second  line  of  buried  sutures  and  union 
of  the  vaginal  flaps. 

outlet  consequent  upon  birth-injury  to  the  levator  ani 
muscle,  with  partial  or  complete  descent  of  the  blad- 
der, rectal  wall,  or  uterus,  all  of  which  must  be  cor- 
rected coincidentally  with  the  above  procedure  to 
assure  permanency  of  result. 


FUNCTJOXAL  URIXARV  JXCOXTJNENCE. 


237 


Incontinence  from  a  Paraurethral  Opening  of  an 
Abnormal  Ureter. — An  anomalous  type  of  perma- 
nent urinary  incontinence,  congenital  in  nature,  is 
due  to  a  minute  ureteral  opening  in  the  vaginal  vesti- 


Fig.  113. — Kelly's  mattress  suture  for  shortening  the  relaxed 
vesical  sphinctre.  The  sphinctre  is  located  by  the  bulb  of  a  re- 
tention catheter  drawn  into  the  vesical  outlet,  as  shown  by  dotted 
lines. 


bule,  just  lateral  to  the  edge  of  the  external  urinary 
meatus. 

The  clinical  vicissitudes  of  such  a  patient  are  typi- 
fied by  the  following  case: — 


238 


GYNECOPLASTIC   TECHNOLOGY. 


Miss  D.,  nurse,  23  years  old,  single,  suffered  from 
incontinence  all  her  life.  During  childhood  she  was 
treated  for  "enuresis,"  then  for  a  "weak  bladder." 
Later  in  life  she  was  pronounced  a  "neurotic."     One 


Fig.  114. — Shortening  of  the  vesical  sphinctre  for  functional  incon- 
tinence.   Baldy's  re-enforcing  suture  over  the  repaired  area. 


surgeon  attributed  her  incontinence  to  a  "floating 
kidney,"  and  performed  a  nephropexy  on  the  right 
side. 

The  persistence  of  the  condition  prompted  another 
surgeon  to  remove  her  left  kidney  for   "tubercular 


FUNCTIONAL  URINARY  INCONTINENCE.  239 

nephritis."  The  leak  continuing-,  a  third  surgeon  sub- 
jected her  to  a  urethroplastic  procedure,  four  months 
after  which  the  patient  came  under  the  author's 
observation. 

On  distending  her  bladder  with  methylene  blue 
solution,  the  total  absence  of  the  coloring  substance 
in  the  leaking  urine  at  once  established  both  the  in- 
tegrity of  the  vesical  sphinctre  and  the  ureteral 
source  of  the  incontinence. 

The  anomalous  opening  was  exposed,  after  a  pro- 
longed and  tedious  search,  as  a  very  minute  orifice, 
concealed  by  a  minature  contractile  valve  of  mucosa, 
located  just  within  the  right  lateral  margin  of  the  ex- 
ternal urinary  meatus.  This  diminutive  opening 
contracted  periodically  like  a  normal  ureteral  orifice 
within  the  bladder. 

The  patient  was  cured  by  dissecting  the  para- 
urethral ureter  from  the  para-urethral  tissues  on  an 
inserted  probe,  and  implanting  its  free  end  into  the 
base  of  the  bladder. 

These  cases  are  not  as  rare  as  the  paucity  of  re- 
ports would  indicate.  Anomalous  and  supernumer- 
ary ureters  are  quite  common,  and  when  such  aber- 
rant ureters  open  into  the  urethra  or  vaginal  vestibule 
a  permanent  incontinence  must  ensue,  which  can  be 
corrected  onl}^  by  a  ureterovesical  implantation, 
which,  in  most  of  the  cases,  may  be  successfully  ac- 
complished per  vaginum. 


CHAPTER  XXI. 

Exstrophy  of  the  Bladder.  ' 

This  is  a  congenital  deformity  in  which  arrested 
fetal  development  resulted  in  a  diastasis  between  the 
two  lateral  halves  of  the  anterior  bladder  wall  and  of 
all  the  tissues  in  front  of  it,  including  the  abdominal 
parieties,  the  pubic  bones,  and  the  roof  of  the  urethra, 
the  gap  being  filled  by  the  forward  bulging  of  the 
bladder  base. 

The  clitoris  is  cleft,  and  the  labia  majora  and 
minora  are  widely  separated,  while  the  urethra  as 
such  is  totally  absent. 

Up  to  recent  years  this  most  deplorable  affliction 
defied  all  corrective  efforts.  Much  zeal  and  inge- 
nuity were  expended  in  repeated  futile  attempts  to 
bridge  these  extensive  defects  by  various  plastic 
methods,  the  best  results  of  which  were  a  small  uri- 
nary sac,  chronically  inflamed,  and  subject  to  recur- 
ring calculus  formation,  demanding  constant  treat- 
ment. 

In  a  number  of  cases  such  plastic  procedures 
secured  a  covering  for  the  protruding  vesical  cavity, 
and  thus  converted  the  bulging  mass  of  bladder  wall 
into  a  closed  urinary  reservoir,  but  no  method  had 
established  the  sphincteral  retentive  function  essen- 
tial to  the  cure  of  the  condition. 

The  ver}^  operations  that  secured  the  most  com- 
plete closure  of  the  defect  were  farthest  from  afford- 
ing relief  to  the  -patients,  as  in  just  these  instances 
(240) 


EXSTROPHY  OF  THE  BLADDER.         241 

decomposition  of  urine,  phosphatic  incrustations  and 
irritating  secretions  from  the  inner  surface  of  the 
artificial  bladder  wall,  almost  invariably  necessitated 
a  reopening  of  the  cavity  for  free  drainage  and 
cleansing  purposes. 

In  1894  Maydl  first  introduced  the  modern  prin- 
ciple of  diverting  the  urinary  flow  by  transplanting 
the  bladder  trigone,  with  both  ureters  intact,  into  the 
sigmoid,  then  dissecting  out  the  remainder  of  the 
bladder,  and  closing  the  abdominal  aperture  by  an 
autoplastic  method  suitable  to  the  case. 

He  thus  preserved  the  essential  controlling  mech- 
anism of  the  ureterovesical  orifices. 

Hartley  collected  the  results  of  46  cases  operated 
upon  by  this  method,  with  an  ultimate  mortality  of 
15  per  cent. 

The  principal  danger  of  Alaydl's  operation  lies  in 
its  transperitoneal  course.  Moynihan  obviates  this 
danger  by  first  catheterizing  the  ureters,  then  excis- 
ing the  entire  bladder  wall,  and,  after  stripping  the 
intact  rectovesical  peritoneum  upwards,  he  incises  the 
rectum  and  implants  the  bladder  base  into  the  rectal 
lumen. 

As  Maydl's  original  operation  and  Moynihan's 
extraperitoneal  modification  are  anatomically  im- 
practicable in  the  female,  George  A.  Peters,  of 
Toronto,  elaborated  the  following  method  of  extra- 
peritoneal transplantation  of  each  ureter  into  the  cor- 
responding side  of  the  rectum,  taking  with  the  ureter 
enough  of  the  bladder  wall  to  preserve  the  uretero- 
vesical musculature : — 

With  a  guiding  catheter  in  each  ureter,  the  ex- 
cision of  a  button  of  bladder  wall  is  begun  on  the 

16 


242  GYNECOPLASTIC   TECHNOLOGY. 

lower  or  pubic  side  of  the  ureteral  orifices,  thus 
avoiding  the  peritoneum. 

A  finger  in  the  cellular  space  thus  opened  contin- 
ues the  dissection  bluntly  to  the  peritoneal  reflection. 

When  the  button  of  bladder  wall  is  entirely  free, 
the  ureter  is  readily  brushed  from  its  loose  surround- 
ings  and   carefully   followed   back   without   traction 


Fig.  115. — Operation  for  exstrophy  of  the  bladder.  Uretero- 
intestinal  anastomosis  (Mayo.)  Ureter  ready  to  be  drawn  through 
incision  into  the  lumen  of  the  large  bowel. 

until  enough  is  mobilized  to  secure  an  approximately 
straight  course  from  the  brim  of  the  pelvis  to  its  new 
location  in  the  lateral  rectal  wall. 

The  transplantation  should  be  made  just  above 
the  internal  rectal  sphinctre.  A  forceps  is  carried 
through  the  anus  into  the  rectum  and  pressed  against 
the  selected  spot,  where  a  slight  incision  enables  the 
forceps  to  penetrate  when  it  is  spread  just  sufficient 


EXSTROPHY  OF  THE  BLy\DDER. 


243 


to  make  an  opening  that  will  hold  the  ureter  snugly 
by  means  of  one  or  two  sutures. 

After  drawing  the  button  of  bladder  into  the  rec- 
tal opening,  the  catheter  is  removed  from  the  ureter, 
and  when  both  sides  are  completed,  Peters  leaves  a 
small  drainage-tube  in  the  rectum.  The  latter  is 
unnccessarv. 


Fig.  116. — Operation  for  exstrophy  of  the  bladder.  Uretero- 
intestinal  anastomosis.  (Mayo.)  Ureter  infolded  into  large  bowel, 
similar  to  gastrostomy. 


Peters  cured  each  one  of  his  5  original  cases,  4  of 
which  are  still  living  and  well.  They  retain  their 
urine  from  one  to  four  hours  during  the  day,  and 
from  six  to  eleven  hours  during  the  night. 

Lendon,  of  Australia,  performed  an  exactly  simi- 
lar operation  May  22,  1899 — two  months  before 
Peters'  first  operation — and  another   in  July,    1901, 


244  GYNECOPLASTIC   TECHNOLOGY. 

but  his  two  cases  were  not  published  until  1906.  In 
the  same  issue  (Brit.  Med.  Jour.,  April  28,  1906) 
Newland,  of  Australia,  records  a  case,  and  in  the 
same  journal  of  May  19,  1906,  is  the  report  of  a  case 
by  Bond,  of  England. 

Sherman,  of  San  Francisco,  reports  a  successful 
case  done  by  the  Peters  method,  and  quotes  one  of 
Pye  Smith.  This  makes  10  cases,  with  two  deaths — a 
record  that  will  be  improved  upon  with  greater  per- 
fection of  technique. 

Peters'  operation  preserves  the  ureterovesical  mus- 
culature, as  do  the  Maydl  and  Moynihan  procedures. 
It  is  entirely  extraperitoneal.  Its  simplicity  and  ease 
of  execution  result  in  a  minimum  of  trauma,  and 
therefore  in  greater  likelihood  of  a  proper  immediate 
ureteral  function.  The  infection  of  the  peritoneum 
is  eliminated,  and  ultimate  contractures  and  strict- 
ures about  the  ureters  obviated. 

The  remainder  of  the  bladder  should  be  removed 
at  a  subsequent  operation,  when  cicatricial  contrac- 
tion and  the  dry  state  of  the  tissues  offer  more 
favorable  conditions  for  autoplastic  closure  of  the 
residual  abdominal  defect. 

In  a  recent  article  reviewing  the  subject  to  date, 
Charles  H.  Mayo  discards  Peters'  operation,  and 
questions  the  competence  of  the  ureterovesical  im- 
plant to  prevent  ascending  renal  infection. 

Mayo  contends  that  "Nature's  method  of  empty- 
ing a  duct  is  always  by  indirection.  Thus,  the  sali- 
vary ducts,  the  common  duct  of  the  liver,  and  the 
ureters  pass  through  the  muscularis,  and  continue  for 
a  distance  between  the  mucous  membrane  and  the 
firmer  outer  wall  of  the  cavity.    Pressure  from  within 


EXSTROPHY  Ui'   THE  BLADDER.  245 

compresses  the  ducts,  and  blocks  against  dilatation 
and  ascending'  infection.  The  fact  seemingly  was 
not  recognized  that  the  mechanical  principle  of  the 
passage  of  the  ureter  through  the  wall  of  the  bladder 
and  its  mucosa  could  not  be  retained  after  the  loss  of 
its  innervation.  .  .  .  The  secret  of  successfully  an- 
astomosing the  ureter  into  the  bowel  is  to  tubularize 
the  ureteral  entrance  for  i}i  inches." 

On  the  basis  of  this  contention,  he  reverts  to  the 
transperitoneal  implantation  of  the  ureters  into  the 
sigmoid.  The  inherent  dangers  of  this  formidable 
procedure,  as  compared  with  the  Peters  operation, 
are  in  no  measure  offset  by  the  purely  theoretical  ad- 
vantage as  set  forth.  Mayo's  record  of  13  successful 
cases,  with  only  one  operative  death,  attests  the  tech- 
nical skill  of  the  operator  rather  than  the  safety  of 
the  method  employed. 


CHAPTER  XXII. 

Fecal  Fistula. 

The  fecal  fistulse  within  the  range  of  gynecoplas- 
tic  operations  comprise: — 

I.  Enterogenital. 

II.  Enterovaginal. 
HI,  Rectovaginal. 

IV.  Rectoperineal. 

V.  Postrectal  (congenital  cysts). 

An  enterogenital  fistula  communicates  between 
some  part  of  the  intestinal  lumen  (not  including  the 
rectum)  and  the  generative  organs.  The  condition  is 
not  common.  Lieblein  and  Hilgenreimer  found  only 
122  cases  in  the  entire  literature  of  the  subject. 

These  fistulse  may  be  congenital  or  acquired.  The 
latter  result  from  traumatism  during  attempted  abor- 
tion, parturiental  accidents  or  injuries,  and  extra- 
uterine pregnancy. 

In  28  cases  of  enfero-nterine  fecal  fistula  collected 
by  Neugebauer,  one-half  were  due  to  retained  ne- 
crotic foetal  parts ;  the  remainder  followed  forceps 
application,  or  rupture  of  the  uterus  during  delivery. 

The  uterus  or  vagina  may  be  perforated;  a  loop 
of  intestine  protruding  through  the  rent  becomes 
strangulated  and  sloughs. 

The  puerperal  uterus  may  be  penetrated  by  the 
curette  or  finger  in  removing  placental  remnants. 

In  postpartem  sepsis  an  adherent  coil  of  intestine 
may  be  invaded  by  suppuration  of  a  pelvic  exudate, 
(246) 


FECAL   FISTULA. 


247 


or  punctured  by  an  incision  in  the  posterior  vaginal 
fornix  for  the  evacuation  of  pus. 

Among  the   estabhshed   non-puerperal   causes  of 
enterogenital   fistulse    are    forcible   dilatation   of   the     ^ 
cervix;   pessaries;   clamping  and  injudicious   gauze- 
packing  during  vaginal  hysterectomy. 

Such  fistulae  may  also  originate  from  primary  in- 
testinal conditions,  as  tuberculosis,  syphilis,  appendi- 
citis, diverticulitis  or  malignant  growths. 


Congenital 

Fistulas  of  Genital  Origin 

Intestinal 
origin 

Unknown 
origin 

Total 

Puerperal 

Post- 
operative 

Other 

1 

47 

47 

12 

5 

13 

125 

The  order  of  frequency  in  the  occurrence  is:  I., 
enterovaginal ;  II.,  entero-uterine ;  III.,  enterotubal. 
Among  I02  cases,  59  were  vaginal,  41  uterine,  and 
2  tubal. 


No.  of  Cases 

No.  of  Fistulous  Openings 

Total 

Varieties 

Small 
Intestine. 

Large 
Intestine 

Large  and 

small 

Intestine 

No.  of 
Fistulae 

Entero- 
vaginal 

57 

46 

10 

3 

59 

Entero- 
uterine 

37 

25 

13 

3 

41 

Enterotubal 

2 

2 

2 

Postoper- 
ative 

26 

24 

3 

•• 

27 

Total 

122 

95 

28 

6 

129 

248 


GYNECOPLASTIC    TECHNOLOGY. 


The  location  of  the  fistulse  (as  shown  in  this 
table,  from  Lieblein  and  Hilgenreimer)  is  in  the 
small  bowel,  and,  as  a  rule,  in  its  movable  segments. 
It  follows  that  all  plastic  attempts  through  the  vagina 
are  attended  by  technical  difficulties  that  jeopardize 
the  outcome  by  enhancing  the  possibility  of  infection 
and  disaster,  the  abdominal  route  offering  greater 
access,  facility,  and  safety  for  any  indicated  entero- 
plastic  procedure,  which,  when  successful,  is  invari- 
ably followed  by  a  spontaneous  closure  of  the  vaginal 
opening. 

While  some  of  the  cases  may  heal  spontaneously 
after  a  varying  period  of  time,  the  majority  demand 
operative  intervention,  as  shown  in  the  following 
table : — 


Variety- 

No n- operated  Cases 

Operated  Cases 

O 

o 
u 

& 

a 

-a 

2  ft 

a 

5 

3 

o 

-a 

u 
3 
O 

•a 

> 
o 

ft 

a 

a 

5 

CO 

o 

Post- 
operative 
FistulEe 

11 

•• 

2 

13 

3 

•  • 

•  • 

3 

Other 
Fistulse 

15 

12 

1 

20 

48 

12 

1 

3 

6 

22 

Total 

26 

12 

1 

22 

61 

15 

1 

3 

6 

25 

The  mortality  in  these  patients  is  materially  aug- 
mented by  delay  in  operating. 

Rectovaginal  Ustiila  is  a  direct  pathological  com- 
munication between  the  vagina  and  rectum.  Surgic- 
ally, this  variety  should  be  classified  as  follows : — 

I.  Openings  into  the  upper  region  of  the  recto- 
vaginal septum. 


FECAL   FISTULA.  249 

II.  Openings  involving  the  more  central  zone. 

III.  Those  presenting  in  the  sphincteral  region. 
The  first  and  second  class  are  most  frecjuently  due 

to  malignant  or  syphilitic  ulceration,  more  rarely  to 
trauma;  while  the  third  class  almost  invariably  re- 
sults from  parturiental  or  operative  injury. 

Rectoperineal  fistulse  frequently  follow  unsuccess- 
ful attempts  at  repair  for  complete  perineal  laceration 
extending  into  the  anterior  rectal  wall. 

A  fistulous  tract  connecting  the  rectum  and  one 
of  the  labia  presents  an  extension  of  burrowing  ab- 
scess formation  from  the  ischiorectal  fossa,  usually 
tubercular  in  nature. 

Rectovaginal  fistulse  of  cancerous  origin  are  in- 
curable. 

An  operation  for  fistula  resulting  from  syphilitic 
or  tuberculous  ulceration  will  fail  unless  preceded  by 
appropriate  constitutional  measures. 

The  same  technical  principles  that  govern  opera- 
tions for  the  cure  of  vesicovaginal  fistulse  apply  to 
the  treatment  of  rectovaginal  fistulse. 

In  all  cases,  when  the  patient  is  anesthetized,  the 
anal  sphinctre  should  be  incised  or  properly  stretched 
as  an  essential  preliminary. 

To  secure  ample  mobilization  and  redundancy  of 
the  involved  tissue  layers,  the  mucosa  of  the  posterior 
vaginal  wall  should  be  incised  like  that  of  the  anterior 
vaginal  wall  in  vesicovaginal  fistula,  and  the  rectum 
dissected  from  the  vagina  for  at  least  i^  inches 
around  the  fistular  margins. 

Firm  closure  of  the  rectal  defect  without  undue 
tension  should  be  secured  by  interrupted  absorbable 
Lembert  sutures,  introduced  from  the  vaginal  aspect. 


250  GYNECOPLASTIC   TECHxNOLOGY. 

SO  as  to  extend  to,  but  not  through,  the  rectal  mucosa. 
Before  suturing  the  vaginal  mucosa,  the  levator  ani 
should,  if  possible,  be  interposed  between  the  vaginal 
and  rectal  wall,  as  described  in  the  chapter  on  Peri- 
neorrhaphy, thus  securing  an  additional  barrier 
against  recurrence. 

A  rectoperineal  fistula  demands  complete  division 
of  the  perineum  through  the  sphinctre  ani  along  the 
course  of  the  fistulous  tract  to  its  origin  in  the 
rectum. 

The  fistulous  tract  should  be  exsected,  and  the 
tissues  accurately  reunited,  as  in  cases  of  recent 
complete  perineal  tear. 

Fistulae  situated  high  between  rectum  and  vagina, 
like  the  inaccessible  vesicovaginal  fistula,  may  neces- 
sitate the  paravaginal  incision  of  Schuchardt,  already 
described. 

In  large  rectal  defects  extending  laterally,  it  is 
sometimes  advantageous  to  liberate  the  anterior  rec- 
tal wall  for  from  2  to  3  inches  above  the  upper 
margin  of  the  fistula.  This  is  drawn  down  and  at- 
tached to  the  cutaneous  anal  margin,  and  the  split 
sphinctre  ani  united  over  it  by  a  buried  suture 
(Noble). 

The  most  frequent  cause  of  failure  in  rectovaginal 
as  in  vesicovaginal  fistula  is,  deficient  liberation  of 
the  fistular  layers  from  one  another. 

Postrectal  FistulcB  (Cysts;  Congenital  Fistulse). 
— These  infected  congenital  defects  result  from  fail- 
ure of  embryonal  occlusion  of  the  neuro-enteric  canal. 
There  may  be  simple  pilonidal  cutaneous  involucra 
(dermonidal  cysts),  or  postrectal  dermoid  pockets 
communicating  wnth  the  rectum  (mucous  exclusion). 


FECAL   FISTUL.^.  251 

or  a  fistula  may  lead  from  the  skin  to  the  mucosa  of 
the  bowel. 

The  variety  which  concerns  us  here  is  the  post- 
rectal  fistula  communicating  with  an  epithelium-lined 
pocket  behind  the  rectum. 

A  retrorectal  dermoid  may  become  infected  and 
rupture  into  the  rectum,  discharging  pus  and  dermoid 
debris  for  months  or  years.  A  sinus  or  opening  in 
the  postrectal  region  discharging  pus,  hair,  or  debris 
would,  of  course,  lead  to  a  diagnosis,  but  the  surgeon 
rarely  sees  the  case  in  this  condition.  He  finds 
merely  an  opening  leading  to  a  suppurating  cavity, 
or  the  patient  complains  of  a  periodical  discharge  of 
pus  from  the  bowel,  the  source  of  which  may  not  at 
the  time  be  apparent,  owing  to  intermittent  closure 
of  the  fistulous  opening. 

The  afTected  parts  may  be  reached  by  a  sacro- 
iliac incision  close  to  the  margin  of  the  sacrum  and 
coccyx,  or  by  a  Kraske  incision. 

On  reflecting  the  bony  flap,  the  wall  of  the  sac 
can  be  freed  from  all  of  its  attachments,  severed  from 
the  rectum,  and  removed. 

A  mural  and  an  extramural  double  row^  of  ab- 
sorbable sutures  should  close  the  rectal  defect;  the 
bony  flap  is  replaced,  and  the  postprocteal  space 
drained. 

This  class  of  fistulse  is  generally  mistreated,  since 
neither  simple  incision  and  drainage  nor  cauteriza- 
tion can  efifect  a  cure.  The  cavity  is  lined  with  epi- 
thelial cells  presenting  essentially  an  organic  secret- 
ing tissue  curable  by  nothing  short  of  radical 
extirpation. 


CHAPTER  XXIII. 

Cancer  of  the  Vulva. 

The  records  of  primary  vulvar  cancer  to  date 
embrace  about  271  reports  (Stein). 

Among  II 77  cases  of  malignant  disease  involv- 
ing the  female  genitalia,  tabulated  by  Schwarz,  30 
were  of  primary  vulvar  origin. 

While  primary  vulvar  cancer,  like  cancer  in  gen- 
eral, is  a  disease  of  advanced  life,  youth  is  by  no 
means  exempt.  A  number  of  cases  are  recorded  that 
developed  in  women  under  30  years  of  age.  Ossing 
refers  to  a  case  in  a  girl  of  20. 

Primary  cancer  of  the  vulva  almost  invariably 
originates  from  the  squamous  epithelium  of  the  af- 
fected area,  and  thus  presents  the  clinical  and  histo- 
logical features  of  tegumentary  epithelioma,  although 
a  few  scattered  instances  of  adenocarcinoma  origi- 
nating in  the  vulvovaginal  and  Skenes  glands  are 
recorded. 

The  most  frequent  starting-point  of  the  disease 
is  the  inner  aspect  of  the  right  labium  minus,  below 
the  clitoris,  the  other  sites  of  origin  in  their  order  of 
occurrence  being:  the  sulcus,  between  the  labium 
minus  and  majus ;  the  anterior  and  posterior  commis- 
sures; the  clitoris;  the  urinary  meatus;  and  the 
vulvovaginal  glands. 

Papillary  excrescences  at  the  mucocutaneous 
margins,  and  other  local  irritative  processes  in  el- 
(252) 


CANCER  OF  THE  VULVA. 


253 


derly  women,  manifest  a  decidecl  predisposing  tend- 
ency to  the  development  of  malignant  disease,  which 
ordinarily  begins  as  a  circumscribed  superficial  infil- 
tration, gradually  developing  one  of  two  distinct 
clinical  types  in  its  progress : — 


Fig.   117. — Adenocarcinoma  of  the  left  vulvo- 
vaginal gland.     (Kelly.) 


I.  A  more  or  less  prominent  nodular  or  papillary 
outgrowth,  with  a  tendency  to  the  formation  of 
"epithelial  pearls"  and  cornification. 

The  outgrowth  may  attain  the  size  of  an  orange; 
its  surface  becomes  excoriated,  and  sooner  or  later 
breaks  into  necrotic  ulcers. 


254 


GYNECOPLASTIC    TECHNOLOGY. 


11.  is  the  more  virulent,  and  presents  a  diffuse 
surface  infiltration  rather  than  circumscribed  tumor 
formation,  characterized  by  a  flat  elevation  of  the 
deeply  infiltrated  area,  in  which  early  necrobiosis  re- 
sults   in    sloughing   patches,    with   typical    irregular, 


Fig.  118. — Primary  carcinoma  of  clitoris  developing  on 
a  basis  of  condjdomata  acuminata.     (Taussig.) 


indurated    edges,    and    a    grayish,    friable,    coarsely 
granular  base,  exuding  a  foul  discharge. 

Involvement  of  the  inguinal  lymphatics  occurs 
early  in  the  latter  form  of  the  disease,  and  contact 
implantations  have  been  noted. 


PLATE  XXI. 


Circumscribed  epithelioma  of  the  vulva. 


/ 


Diffuse  ulcerative  epithelioma  of  the  vulva. 


CANCER  OF  THE  VULVA. 


As  a  rule,  ihc  process  extends  toward,  but  not 
into,  the  vagina,  usually  advancing"  upward  into  the 
groin  and  down  over  the  perineum. 


Fig.  119. — The  lymphatics  of  the  external  genitalia.     (Crossen.) 


The  average  duration  of  life  in  unoperated 
patients  is  about  two  years. 

In  no  class  of  cancer  cases,  wnth  the  possible  ex- 
ception of  primary  adenocarcinoma  of  the  corporeal 


256 


GYXECOPLASTIC   TECHXOLOGY. 


endometrium,  is  early  radical  extirpation  so  uni- 
formly curative  as  in  primary  vulvar  epithelioma. 

Such  an  extirpation  implies  a  total  exsection  "en 
hloc"  of  all  the  involved  vulvar  structures,  including 
the  inguinal  lymphatics  on  both  sides. 

Poirier  and  Cuneo  give  the  following  account  of 
the  vulvar  lymphatics,  quoting  in  part  from  Sappey's 
older  work: — 


Fig.  120. — The  lymphatics  of  the  urethra  and  anterior  part  of  the 
vagina  pass  directly  backward  to  glands  in  the  interior  of  the 
pelvis.      (Crossen.) 


"The  lymphatics  of  the  vulva  arise  from  a  net- 
work, the  extremely  close  meshes  of  which  are  super- 
posed in  several  planes.  This  network  covers  the 
fourchette,  the  meatus  urinarius,  the  vestibule,  the 
clitoris,  the  labia  minora,  and  the  internal  surface  of 
the  labia  majora.  It  is  so  loose  and  close  throughout 
that  when  it  has  been  well  injected  it  presents  at 
first  sight  merely  an  ashy-gray  appearance.     To  dis- 


CANCER  OF  THE  VULVA.  257 

tinguish  the  innumerable  silvery  filaments  of  which 
it  is  composed,  we  must  use  a  magnifying  glass.     On 
the  external  surface  of  the  labia  majora  the  network 
composed  of   smaller   and   larger   branches   becomes 
sufficiently   distinct   to   be   recognized  by  the   naked 
eye"  (Sappey).    "From  the  periphery  of  this  network 
of  origin  run  the  collecting  trunks.    The  direction  of 
these  trunks  varies  according  to  their  point  of  origin. 
Those  which   come  from  the  anterior   third  of  the 
vulva  run  directly  upward  and  forward  toward  the 
mons  veneris ;  there  they  turn  sharply  and  run  trans- 
versely toward  the  superficial  inguinal  glands.     The 
trunks  which  come  from  the  posterior  two-thirds  are 
directed   upward    and   outward,    and   directly    reach 
their   terminal   glands.      The   majority   of   the   lym- 
phatics of  the  vulva  terminate  in  the  glands  of  the 
internal-superior  group.     Some  of  them  may  end  in 
the    internal-inferior    group.      It    is    even    possible, 
though  much  more  rare,  to  see  some  of  these  vessels 
reach  a  gland  belonging  to  one  of  the  two  external 
groups.     The  vulvar  lymphatics  are  far  from  being 
confined    to    a    perfectly    definite    glandular    group. 
When  injecting  one-half  of  the  vulva  the  mass  may 
frequently  be  seen  to  reach  the  glands  of  the  opposite 
side.     The  injection  of  these  glands  may  take  place 
by  a  double  process.     Sometimes  it  is  effected  on  ac- 
count of  the  continuity  of  the  network  of  origin  of 
the  two  sides  of  the  vulva  in  the  middle  line ;  at  others 
it  is  due  to  the  fact  that  some  of  the  collecting  trunks 
cross  the  middle  line  and  end  in  the  inguinal  region 
of  the  opposite  side.     In  all  cases,  when  dealing  with 
an  epithelioma  of  the  vulva,  the  inguinal  glands  of 
both  sides  should  be  regarded  as  liable  to  infection. 

17 


258 


GYNECOPLASTIC    TECHNOLOGY. 


urcS 
V-.     - 
dans  clitoriUi^ 


Heep  dor-sot  Its  cZcfarii^rJ'lf- 
'  ''  "  cere.  ■ 


Uee-p 
ifors.  c/ito/-ic(i  V  n 


ctrmar'ict^ 


A.rtjl>f6u/// 


Vuii^&-voc^erta/ 

Levator  fascia^ 
Tendinous  centra 
of  the  perineum 


— J'roZia 


7      ^        ^€.   t./^ 

iit/'"',  re/'/ecfeeC 
y•e/'^ectea 


Fig.  121. — Regional  layer  dissection  of  vulvar  structures. 


CANCER  OF  THE  VULVA.  259 

Surgical  interference  in  epitlielial  tumors  can  be  effi- 
cient only  when  combined  with  radical  extirpation  of 
the  glands,  for  the  lymphatics  are  invaded  from  the 
very  beginning,  and,  although  sometimes  apparently 
intact,  are  always  altered  histologically." 

The  lymphatics  of  the  clitoris,  instead  of  passing 
into  the  superficial  inguinal  glands,  like  the  other 
vulvar  lymphatics,  pass  from  the  primary  plexus  in 
several  collecting  trunks  along  the  dorsal  surface  of 
the  clitoris  to  the  front  of  the  symphysis,  where  they 
anastomose,  forming  a  plexus  which  gives  oft*  two 
sets  of  collecting  trunks.  One  lymph-vessel,  passing 
along  the  inguinal  canal  to  the  external  retrocrural 
gland,  is  usually  encountered  beneath  the  round  liga- 
ment, while  other  lymphatics  pass  toward  the  crural 
to  their  termination  in  a  deep  inguinal  gland,  the 
internal  retrocrural  gland  and  the  so-called  gland  of 
Cloquet. 

The  urethral  lymphatics  in  the  female  drain  into 
the  middle  and  outer  chain  of  the  external  iliac 
glands,  the  hypogastric  glands,  and  the  glands  of  the 
promontory. 

The  practical  application  of  these  anatomical  find- 
ings is  very  clearly  and  concisely  summarized  by 
Crossen  ("Operative  Gynecology,"  1915,  p.  476)  as 
f  ollow^s : — 

I.  "From  a  cancer  of  the  labium  majus  or  minus 
all  the  lymphatic  distribution  in  the  early  stage  is 
likely  to  be  to  the  inguinal  glands. 

II.  "This  distribution  may  extend  not  only  to  the 
side  on  which  the  lesion  is  located,  but  also  to  the 
opposite.  Hence  the  glands  on  both  sides  should  be 
removed. 


260 


GYNECOPLASTIC    TECHNOLOGY. 


T 


'W~,^ 


,i&i    'cxm 


% 


r 


T^^n  dZTi  oi^j- 

t  treofthejyer-fTt  - 


Fig.  122. — Regional  layer  dissection  of  the  vulvar  structures. 


CANCER  01'   THE  VULVA. 


261 


III.  "In  cancer  of  the  clitoris,  a  very  early  dis- 
tribution to  the  glands  inside  the  pelvis  is  probable. 

IV.  "In  cancer  of  the  urethra  also,  invasion  of 
the  interior  of  the  pelvis  is  favored  by  the  lymphatic 
distribution." 

Technically,  the  operation  for  cancer  of  the  vulva 
should   conform   strictly   to   the   established   modern 


Fig.  123. — Outlines  for  the  "block  excision"  of  the 
external  genitals.     (Crossen.) 


principles  of  radical  cancer  extirpations  "en  bloc" , 
that  is,  commencing  with  the  exsection  of  the  ingui- 
nal lymphatics  and  ending  with  that  of  the  vulva,  the 
whole  involved  area  is  removed  from  above  down- 
wards in  its  entirety,  as  one  unbroken  block,  which 
includes  the  glands,  the  lymph-vessels  and  the  vulvar 
tissues,  with  an  ample  margin  of  uninvolved  skin. 

To  obviate  dissemination,  this  entire  dissection  is 
conducted  through  the  surrounding  healthy  tissues. 


262 


GYNECOPLASTIC   TECHNOLOGY. 


as  wide  of  the  disease  as  feasible,  and  all  rough  ma- 
nipulation of  the  cancerous  structures  is  scrupulously 
avoided. 

In  the  following  adaptation  from  Crossen,  Stein 
summarizes  the  stages  in  the  operative  technique  as 
follows : — 

First  step:     "Circumferential  skin  incision  of  the 


Fig.  124. — First  step  in  the  "block  excision."     The  inguinal 
gland-tissue  dissected  out.     (Crossen.) 


surface  to  be  removed,  including  a  wide  margin 
about  the  lesion,  extending  outward  over  the  lym- 
phatics on  each  side.  Where  the  vulvar  lymphatics 
are  more  deeply  situated  a  linear  continuation  of  the 
incision  and  reflection  will  be  sufficient." 

As  some  of  the  lymph-vessels  run  upward  for  a 
considerable  distance  before  turning  outward,  while 
others  decussate,  it  is  necessary  to  excise  the  super- 
ficial tissues  well  up  over  the  pubes. 


CANCER  OF  THE  VULVA. 


263 


Second  step:  "Block  dissection  of  the  gland- 
bearing  area  on  each  side,  including  the  adjoining 
tissues  and  the  contents  of  the  saphenous  opening, 
where  injury  to  the  deep  veins  must  be  carefully 
avoided/' 

From  being  skin  deep  at  first  over  the  gland  areas, 
the  incision,  as  it  approaches  the  vulva,  penetrates  the 
structures  down  to  the  muscles  and  fascia. 


Fig.  125. — The  block  of  tissue  partially  excised.     {Crosseii.) 


Third  step:  "Removal  of  the  tissue  block  'en 
masse/  guarding  against  injury  to  the  urethra." 

Enough  of  the  vestibular  mucosa  should  be  left 
intact  to  cover  the  urethra  and  prevent  cicatricial  dis- 
tortion of  the  urinary  outlet.  This  strip  of  mucosa 
may  be  safely  preserved,  as  its  lymphatics  terminate 
in  the  excised  glands  of  the  groin. 

Fourth  step:  "The  large  raw  area  left  by  the  ex- 
cision is  covered  as  far  as  possible  by  sliding  flaps, 


264 


GYNECOPLASTIC   TECHNOLOGY. 


by  tension  sutures,  and  relaxing  incisions,  the  details 
of  which  will  necessarily  vary  in  different  cases.  It 
is  preferable  to  leave  parts  of  the  wound  to  heal  by 
granulations  than  to  incur  sloughing  by  overten- 
sion.    ..." 


Fig.  126. — Denuded  area  and  flap  outlines  after  the  removal  of 
the  clitoris,  vestibule,  anterior  part  of  the  urethra,  and  labia,  with 
extension  of  the  incisions  for  the  removal  of  the  inguinal  glands. 


The  absolutely  fatal  prognosis  in  advanced  cases 
should  prompt  early  intervention. 

The  inguinal  glands  must  invariably  be  extirpated 
on  both  sides,  whether  demonstrably  involved  or  not, 
and  the  whole  region  of  the  groin  thoroughly  cleared 


CANCER  OF  THE  VULVA.  265 

of  all  lymph-carrying  structures,  similar  to  the  clear- 
ing" of  the  axillary  space  in  mammary  cancer. 

The  extraperitoneal  extirpation  of  deep  glandu- 
lar involvement,  according  to  Stoeckel,  begins  with 
an  incision  parallel  to  Poupart's  ligament,  extending 
from  the  inguinal  ring  to  the  anterior-superior  iliac 
spine,  and  along  the  anterior  third  of  the  pubic  crest. 

The  parietal  peritoneum  is  reflected  toward  the 
median  line,  exposing  the  ureter  in  its  entire  course, 
as  well  as  the  large  iliac  vessels,  when  the  deep  and 
superficial  pelvic  l3anphatics  with  their  enveloping 
connective  tissue  are  removed  in  continuity  with  the 
deep  and  superficial  inguinal  glands. 

A  more  extended  radical  operation  by  an  intra- 
peritoneal method  was  again  advocated  by  Stoeckel 
in  19 1 2,  aiming  to  extirpate  the  hypogastric  glands 
in  addition  to  the  iliac,  the  superficial,  and  deep  in- 
guinal. The  intra-abdominal  glands  are  removed 
through  a  median  laparotomy  incision,  which  is  then 
closed,  and  the  inguinal  glands  removed  by  way  of 
two  oblique  incisions  above  the  inguinal  ligaments. 

At  the  point  where  the  laparotomy  incision  and 
the  curved  incision  from  one  iliac  spine  to  the  other 
meet,  a  vertical  incision  is  applied,  which  passes 
downward  over  the  symphysis  encircling  the  vulva. 
Next,  the  vulvovaginal  tissue  is  detached  from  the 
bone,  together  with  the  tumor.  This  is  followed  by 
suture  of  the  wound  and  permanent  catheterization 
of  the  bladder. 

Routine  laparotomy,  in  Stoeckel's  opinion,  is  a 
very  desirable  preliminary,  and  improvement  of  the 
operation,  and  he  recommends  its  performance  as  a 
valuable  first  step  in  all  operations  for  cancer  of  the 


266 


GYXECOPLASTIC   TECHNOLOGY. 


vulva.  A  patient  recently  operated  upon  by  him  ac- 
cording to  this  plan  made  a  good  operative  recovery. 
In  another  case  which  was  operated  upon  according 
to  the  customary  method — namely,  extirpation  of  the 
total  lymph  gland  apparatus  from  the  anterior-super- 
ior iliac  spines  in  connection  with  the  entire  vulva — 


Fig.  127. — Wound  closed. 


the  wound  healed  by  first  intention,  but  a  small  nodule 
developed  in  the  vaginal  cicatrix  on  the  right  side, 
evidently  an  inoculation-recurrence,  as  it  was  found 
on  examination  to  be  carcinomatous. 

It  is  doubtful  whether  such  extensive  and  formid- 
able operative  invasions  are  justifiable,  more  espe- 
cially  as   the   conviction   generally   prevails   that   in 


CANCER  OF  THE  VULVA.  267 

cases  where  the  disease  has  actually  extended  to  the 
intrapelvic  lymph-nodes  the  extended  radical  proced- 
ures offer  a  forlorn  hope. 

Ordinarily,  the  neighboring  healthy  tissues  are 
sufficiently  mobile  to  permit  of  wound  closure  by 
direct  suture  of  the  skin  and  vaginal  mucosa. 

In  very  extensive  denudations  it  is  necessary  to 
secure  sliding  skin  flaps  from  the  corresponding 
thighs  to  cover  the  defect. 

By  means  of  circumferential  relaxing  incisions, 
it  is  usually  possible  to  approximate  all  the  margins 
without  injurious  tension.  If  at  any  point  this  can- 
not be  accomplished,  the  intervening  gap  may  be  left 
to  heal  by  granulation. 

A  considerable  amount  of  scar  tissue  is  tolerated 
in  this  region  without  disturbance,  provided  the 
urethra  is  not  distorted  by  cicatricial  contraction. 
Hence,  accurate  coaptation,  especially  about  the 
urinary  meatus,  should  be  secured. 


CHAPTER  XXIV. 

Elephantiasis  Vulv^. 

In  its  clinical  application,  the  term  Elephantiasis 
vulvce  designates  a  generic  group  of  local  manifesta- 
tions, linked  by  a  similarity  in  objective  features,  but 
differing  in  their  etiology. 

These  objective  features  are  characterized  by  hy- 
perplasia and  hypertrophy  of  the  vulvar  tegumentary 
and  subjacent  connective  tissue  layers,  concomitant 
with  local  lymph  stasis  and  dilatation  of  the  lymph- 
channels. 

The  clitoris,  labia  minora,  labia  majora,  and  peri- 
neum, in  the  order  named,  present  the  initial  focus 
from  which  the  process  extends,  rapidly  or  slowly, 
involving  the  whole  or  part  of  the  vulvar  region  in  a 
growth  that  may  reach  to  the  knees  and  weigh  30 
or  more  pounds. 

The  surface  of  such  growths  may  be  smooth, 
rough,  warty,  polypoid  or  ulcerated.  It  presents 
macules,  papules,  and  cysts,  very  large  masses  being 
invariably  fissured  and  lobulated. 

Negresses  are  more  prone  to  the  disease  than 
white  women. 

The  disease  is  endemic  in  the  tropics,  as  a  result 
of  filarial  infection,  while  the  non-parasitic  form, 
which  may  occur  in  any  climate,  is  most  frequently 
due  to  syphilis  or  tuberculosis.  But  there  are  many 
cases,  of  obscure  etiology,  that  develop  in  the  course 
(268) 


PLATE  XXIL 


Elephantiasis  of  the  vulva. 


ELEPHANTIASIS   VULV^.  269 

of  various  chronic  inflammatory  lesions,  productive 
of  local  lymph  stasis. 

In  an  article  on  ''Esthiomene  and  Elephantiasis 
Vulvae",  A.  Stein  reports  a  case,  and  reviews  our 
present  knowledge  of  this  indeterminate  class  as 
follows  (see  Fig.  128)  : — 

''During  recent  years  publications  upon  this  sub- 
ject have  been  very  few.  This  is  probably  due  to  the 
fact  that  our  knowledge  of  maladies  of  the  vulva  is 
growing  clearer,  and  we  can  distinguish  ulcerative, 
tubercular,  or  luetic  processes  from  those  of  an  in- 
determinable etiology.  Under  the  latter  heading, 
however,  there  is  a  small  group  of  diseases — better, 
perhaps,  a  clinical  picture — to  which  we  can  apply 
no  better  appellation  than  that  of  'Esthiomene.'  This 
term  was  employed  for  the  first  time  about  sixty 
years  ago  by  Huguier.  He,  like  his  contemporaries, 
knew  no  methods  of  differentiation  among  luetic, 
tubercular,  and  simple  ulcers  of  the  external  female 
genitalia.  Chronic  inflammatory  processes  due  to 
chemical  and  other  non-specific  agents  could  not  be 
separated  from  those  caused  by  specific  organisms. 
It  is  possible,  however,  to  reopen  this  question,  and 
to  analyze  it  more  accurately,  since  our  conception  of 
the  nature  of  syphilis  and  tuberculosis  is  no  longer 
vague,  as  in  the  days  of  Huguier.  ...  It  seems 
clearly  established  that  we  are  dealing  with  a  con- 
dition the  etiology  of  which  is  still  obscure.  ...  It 
may  be  argued  that  the  overgrowth  presents  a  type 
of  true  lymphangioma.  It  will  not  be  diflicult,  how- 
ever, to  show  that  this  is  not  so. 

"Our  conception  of  lymphangioma  is  not  a  per- 
fectly  clear    one,    for   the   simple   reason   that   it   is 


270 


GYNECOPLASTIC   TECHNOLOGY. 


-  / 

'-^""^m 

j 

^Hh  'm 

1 

bIw  ■ 

f 

^^^%^jrJ^S^N  j 

v^M 

:lJlmJ^^B» 

•*^  ■  ♦ii.' 

"l  uU^^ai^^lHl' 

4^B^HHHv 

»'^^^B9HHH|piV         '^^PIRIliP 

t 

Fig.  128. — Elephantiasis.     "Esthiomene"  of  the 
anovulvar  region.     (Stein.) 


ELEPHAXTJASIS    VULV^.  271 

difficult  clinicall}'  and  pathologically  to  distinguish 
between  a  lymph-vessel  new  growth  and  a  lymph- 
angiectasis.  Winiwarter,  Wagner,  and  Unna  have 
attempted  rather  unsuccessfully  to  clear  up  this  sub- 
ject, but  have  succeeded  mainly  in  splitting  hairs. 
One  very  readily  recognized  disease  coming  under 
this  caption,  which  deserves  closer  scrutiny,  is  'lym- 
phangioma circumscriptum  cystoides  cutis.' 

"Clinically,  this  is  characterized  by  the  appearance 
upon  the  skin  of  small,  clear  cysts  from  i  mm.  to  ^ 
cm.  in  circumference,  occurring  in  groups  over  an 
area  of  from  i  to  4  inches.  These  cysts  contain  clear 
serum,  and  have  non-inflammatory  bases.  Occasion- 
ally in  the  subjacent  skin  teleangiectases  are  found. 
At  times  the  blood-vessels  rupture  into  the  cysts, 
causing  their  contents  to  become  hemorrhagic.  The 
disease  is  one  of  youth.  It  is  usually  found  about  the 
neck,  shoulders,  upper  thorax,  lips,  and  even  the 
tongue. 

"Strange  to  say,  the  first  case  in  the  literature,  de- 
scribed by  Tilbury  and  Calcott  Fox  in  1879,  ^^'^^  one 
in  which  the  lesions  were  located  upon  the  perineum 
and  thighs.  In  no  case  recorded  since  then  has  this 
been  observed.  The  patient  was  a  young  man  of 
about  20.  Fox  designated  the  disease  as  lupus  lym- 
phaticus,  and  we  cannot  evade  the  suspicion  that  this 
case  may  serve  as  a  connecting  link  between  the  true 
circumscribed  lymphangioma  and  esthiomene.  A 
further  point  of  similarity  is  furnished  by  Freud- 
weiler,  whose  good  fortune  it  was  to  observe  a  case 
from  its  inception.  The  earliest  manifestations  he 
noticed  consisted  of  small  yellow  spots,  which,  becom- 


272  GYXECOPLASTIC    TECHNOLOGY. 

ins:  raised,  were  ultimately  converted  into  cvsts.  In 
our  patient  all  of  these  stages  of  development  were 
present,  the  flat  lesions  being  situated  upon  the  mens 
veneris,  the  others  further  backward  upon  the  labia. 
In  no  case  in  the  literature  was  any  reference  made 
to  ulceration  or  polypoid  formation. 

''Histologically,  the  lesions  have  been  described  as 
clefts  corresponding  to  lymphatic  spaces  in  the  con- 
nective tissue  of  the  papillary  body  and  cutis.  Some 
were  pear-shaped,  with  the  apex  pointing  downward,, 
and  connected  by  strands  of  cells  with  the  cutaneous 
blood-vessels.  All  contained  lymph-cells;  all  were 
lined  with  endothelium,  sometimes  several  layers 
deep.  Freudweiler  found  no  evidence  of  inflamma- 
tion. AA'aelsch,  on  the  other  hand,  did.  All  other 
investigators  agree  with  Freudweiler. 

"Concerning  the  etiology,  opinions  are  evenly  di- 
vided as  to  whether  the  disease  is  caused  by  prolifer- 
ation of  the  lymph-vessel  endothelium  per  se,  or 
whether  it  is  due  to  lymph-vessel  dilatation.  With- 
out entering  into  this  discussion,  it  seems  unlikely 
that  a  new  growth  in  the  true  sense  of  the  word  can 
depend  for  its  origin  upon  a  process  commonly  re- 
garded as  inflammatory.  In  comparing  our  case,  then, 
to  cvstic  lymphangiomata,  we  note  the  following 
points  of  similarit}^  viz.,  the  presence  of  macules,  pap- 
ules and  cysts.  T^Iore  striking,  however,  are  the  pro- 
nounced dift'erences.  In  lymphangioma  cysticum, 
ulcerations,  hypertrophies,  elephantiasis  are  entirely 
lackinsf,  and  there  are  no  ascertainable  mechanical 
grounds  for  cyst  formation  such  as  are  present  in 
this  case.    Obviously,  then,  we  must  rule  out  the  pre- 


PLATE  XXIII. 


Syphilitic  gummata. 


ELEPHANTIASIS    VULV^.  273 

sumption  that  our  case  is  one  of  lymphangioma  cys- 
ticum,  and  seek  another  diagnosis.  This  we  beheve 
to  be  the  one  ah'eady  mentioned,  namely,  esthiomene." 

While  elephantiasis  of  the  vulva  is  not  a  malig- 
nant disease,  the  intense  pruritus,  the  painful  excori- 
ations, and  the  eventual  impediment  to  urination, 
defecation,  and  copulation,  compel  the  patients  to 
seek  relief,  which  is  afforded  only  by  a  total  extirpa- 
tion of  the  tumefied  areas. 

The  operation  must  be  guarded  by  the  strictest 
aseptic  and  antiseptic  measures,  to  avoid  infection 
and  its  rapid  dissemination  through  the  dilated 
lymph-vessels. 

Before  incising  the  tissues,  all  ulcerated  sur- 
faces should  be  thoroughly  seared  with  a  thermo- 
cautery. 

The  mass  should  be  enveloped  in  moist  bichloride 
gauze  thus  securing  a  firm  hold  for  fixation  and  trac- 
tion, while  the  tissues  about  its  base  are  incised  from 
above  downwards. 

In  very  extensive  extirpations,  Kelly  grasps  the 
gauze-covered  mass  with  the  left  hand,  and  by  trac- 
tion ''forms  a  distinct  pedicle  where  none  exists 
naturally."  This  pedicle  is  transfixed  with  successive 
silkworm  ligatures,  and  the  mass  excised  from  above 
downwards,  tying  each  ligature  before  incising  the 
next  section  of  pedicle. 

The  amputation  is  thus  continued,  excising  and 
closing  area  after  area,  until  the  whole  mass  is  re- 
moved and  the  wound  completely  closed. 

By  this  method  of  sectional  successive  transfixion 
and  closure,  the  ligatures  serve  the  double  purpose  of 
hemostasis  and  coaptation. 

18 


274  GYXECOPLASTIC   TECHXOLOGY. 

These  hypertrophies  should  be  removed  as  early 
as  possible,  before  they  have  attained  to  the  septic 
and  excessively  vascular  stage,  in  which  the  opera- 
tion is  at  best  an  extremely  dangerous  under- 
takinsf. 


CHAPTER  XXV. 

Congenital  Malformations. 

The  congenital  malformations  of  the  female  re- 
productive organs  constitute  a  sharply  defined  clinical 
group  of  anomalies,  in  which  surgical  intervention 
aims  to  correct  defective  menstrual  and  procreative 
functions. 

These  anomalies  are,  almost  without  exception, 
instances  of  arrested  development. 

The  fallopian  tubes,  uterus  and  vagina  represent 
the  normal  end  products  in  the  developmental  trans- 
mutation of  the  two  embryonic  Miillerian  ducts. 

Lying  on  either  side  of  the  Wolffian  body,  and  ex- 
ternal to  its  duct,  the  Miillerian  ducts,  consisting  at 
first  of  solid  strands,  pass  downwards  into  the  allan- 
toic portion  of  the  cloaca.  At  a  later  stage  each  duct 
acquires  a  lumen,  the  lower  portion  of  which,  by  fus- 
ing with  its  fellow  of  the  opposite  side,  forms  the 
uterus  and  vagina,  while  its  upper  part,  remaining 
separate,  forms  the  fallopian  tube. 

Certain  deviations  from  the  normal  sequence  in 
this  developmental  chronology,  such  as  irregularities 
in  the  fusion  of  the  lower  parts  of  the  Miillerian  ducts, 
in  their  mode  of  termination,  their  partial  or  complete 
absence,  or  their  imperforate  condition,  will  account 
for  the  various  congenital  atresias,  abnormal  fistular 
communications,  partial  or  complete  duplications  and 
other  defects,  that  may  involve  different  segments  or 
the  entire  srenital  tract. 


te 


(275) 


276 


GYNECOPLASTIC    TECHNOLOGY. 


The  development  of  the  vulva  and  external  gen- 
erative organs  is  more  complicated  and  less  clear 
than  that  of  the  vaginal  canal  and  uterus,  with  its 
adnexa. 


V.  Aberrans 
Paradidymis  or 
JNephric  pt.  of 
Wolffian  Body. 


II 


III. 


Fig.  129. — Relationship  of  the  sexual  ducts  and  their  rudiments 
in  the  two  sexes.  I,  The  indifferent  primary  type.  II,  The  differ- 
entiation in  the  female.  Ill,  The  differentiation  in  the  male 
{Adami.) 


At  the  posterior  or  lower  end  of  the  embryo  an 
invagination  of  the  ectoderm  occurs,  by  which  the 
cloaca  is  brought  into  communication  with  the  ex- 
terior, thus  forming  the  cloacal  opening  or  primitive 


CONGENITAL   MALFORMATIONS. 


277 


anus.     This  is  followed  by  an  indifferent  stage,  dur- 
ing" which  sex  distinction  is  impossible. 

The  anterior  part  of  the  anal  plate  becomes  thick- 
ened, and  gives  origin  to  a  projection  known  as  the 
"genital  tubercle",  which  is  the  "anlage"  of  the  penis 
in  the  male,  and  the  clitoris  in  the  female. 


Endof  Mul-  J\ 


Genital  process 
{fienis  or  clitoris). 

Fig.  130.— The  indifferent  stage  in  the  development  of  the  gen- 
erative organs  (diagrammatic).  {Piersol,  after  Thompson,  "Ameri- 
can Textbook  of  Obstetrics.") 

On  the  under  surface  of  the  genital  tubercle  ap- 
pears a  groove — the  "genital  groove" — which  passes 
backwards  into  the  cloaca.  In  the  female,  the  edges 
of  this  furrow  become  the  labia  minora,  and  the  in- 
tegument external  to  these  develops  into  the  labia 
majora.  In  the  next  stage,  the  cloaca  is  divided  by  a 
partition — the    rudimentary    perineum — into    an    an- 


278 


GYNECOPLASTIC   TECHNOLOGY. 


terior  and  posterior  cavity,  the  former,  termed  "the 
urogenital  sinus,"  gives  vent  to  the  urinary  and 
sexual  duct  terminals,  while  the  latter  constitutes  the 
permanent  anus. 

In  the  female,  the  sinus  urogenitalis  persists, 
forming  the  vestibule,  the  external  urinary  meatus, 
the  vaginal  introitus,  and  the  hymenal  fold. 


Simbria. 


l/rackus 


Bartholin's 
gland. 


Fig.  131.— Changes  that  take  place  in  the  development  of  the 
female  generative  organs  (diagrammatic).  {Piersol^  after  Thomp- 
son, "American  Textbook  of  Obstetrics.") 


Omitting  the  more  involved  phases  of  academic 
teratology,  these  brief  embryological  outlines  will 
serve  to  reveal  the  complicated  segmental  transmu- 
tations which  must  be  visualized  in  the  elucidation 
and  attempted  correction  of  any  congenital  defect. 
Not  all  such  defects,  however,  can  be  satisfactorily 
explained  on  the  basis  of  developmental  arrest,  and 
in  these  latter  other  pathologic  factors  more  or  less 
conjectural,  such  as  amniotic  compression,  amniotic 


CONGENITAL   MALFORMATIONS. 


279 


adhesions,   fetal  peritonitis,   infantile  vulvitis,   adhe- 
sive colpitis,  etc.,  have  been  invoked. 

While  it  is  generally  accepted  as  a  clinical  axiom 
that  congenital  malformations  and  defects  are  usu- 
ally multiple  and  diverse,  they  may  for  practical  pur- 
poses be  enumerated  under  the  following  pathological 
grouping. 


Epididymis. 


Urachvs 


Fig.  132. — Changes  that  take  place  in  the  development  of  the 
male  generative  organs  (diagrammatic).  (JPiersol,  after  Thomp- 
son, "American  Textbook  of  Obstetrics.") 


GROUP   A. 

Aplasia  and  Hypoplasia  of  the  Fetal  Rudiments. 

1.  Absence  of  the  uterine  appendages. 

2.  Absence  of  the  uterus. 

3.  Absence  of  the   entire  genital  tract,   with   or 
without — 

4.  Pseudohermaphroditism. 

5.  Uterus  unicornis. 


280  GYNECOPLASTIC    TECHNOLOGY. 

6.  Atresias,  which  ma}^  be  cord-hke  or  diaphrag- 
matic, existing  in  the  cervix,  vagina,  hymen  or  vulva. 

7.  Congenital  rectovaginal  or  rectovulvar  fis- 
tulse;  atresia  anivaginalis  or  hymenalis,  cloaca  vagi- 
nalis, or  fistula  rectovestibularis. 

8.  Feminine  epispadias  or  hypospadias. 

GROUP    B. 
Hyperplastic  Anomalies  of  Formation. 

1.  Duplication  of  entire  segments:  Uterus  di- 
delphys. 

2.  Uterus  et  vagina  duplex. 

3.  Duplication  of  the  uterine  appendages;  ova- 
ries; tubal  ostia. 

4.  Uterus  bicornis. 

5.  Duplication  by  a  septum:  Uterus  bicornis 
septus,  or  bicollis,  and  subseptus  or  unicollis,  all 
of  which  may  be  combined  with  vagina  septa  or 
subsepta. 

GROUP    C. 

Arrested  Development  and  Anomalies  of  Infancy 
AND  Puberty. 

1.  Uterus  foetalis. 

2.  Uterus  infantilis  and  uterus  membranaceus. 

3.  Anteflexio  uteri  infantilis. 

4.  Stenosis  cervicis  et  orificii  externi. 

5.  Stenosis  vulvovaginalis  or  hymenalis. 

6.  Evolutio  prsecox. 

7.  Oligomenorrhea  and  amenorrhea. 

8.  Dysmenorrhea. 

9.  Menorrhagia. 
.    10.   Sterility. 


CONGENITAL    MALFORMATIONS.  281 

Of  clinical  import  in  the  foregoing"  enumeration 
are : — 

Absence  of  the  Uterus  ("uterus  deficiens  seu 
clefectus  uteri"). — Complete  absence  of  the  uterus, 
its  adnexa,  and  (to  some  extent  also)  the  external 
genitals  is  usually  encountered  in  the  acardiac  twin 
and  in  sympodial  fetuses;  but  its  occurrence  in  the 
adult  and  otherwise  normal  individual  is  extremely 
rare.  Only  post-mortem  evidences  can  establish  the 
non-existence  of  the  uterus  and  its  adnexa,  and  in 
most  of  the  reported  cases  such  evidence  is  wanting; 
hence  it  is  more  logical  to  assume  that  in  the  majority 
of  these  cases  the  individual  was  a  male  with  unde- 
scended testicles,  not  a  female  without  a  uterus. 

A  woman  without  a  uterus,  or  with  merely  a 
rudimentary  organ,  may  present  all  the  secondary 
characters  of  her  sex.  She  may  have  a  high-pitched 
voice,  rounded  contours,  and  an  absence  of  facial 
hair.  Amenorrhea  is  necessarily  constant.  Never- 
theless, ovulation  may  occur,  and  molimina  become 
manifest,  which  occasionally  assume  an  intensity  that 
demands  removal  of  the  ovaries.  The  shallow  vesti- 
bular vaginal  pouch  may  be  deepened  by  repeated 
attempts  at  coitus,  which  in  most  of  the  cases  is  un- 
consciously practiced  through  the  gradually  dilated 
urethral  opening. 

Uterus  unicornis  is  an  organ  in  which  one  horn 
alone  is  well  developed.  There  are  two  varieties — 
that  in  which  the  second  horn  is  altogether  absent, 
and  that  in  which  it  persists  as  a  solid  or  hollow^  rudi- 
ment. In  the  first  condition  there  is  complete,  in  the 
latter  partial,  defect  of  one  of  the  Aliillerian  ducts. 


282  GYXECOPLASTIC    TECHNOLOGY. 

The  uterus  unicornis  has  no  fundus.  The  single 
horn,  incHning  to  one  side  of  the  middle  line,  tapers 
to  a  point  at  which  it  is  continuous  with  the  fallopian 
tube  and  the  origin  of  the  round  ligament.  The  cer- 
vix is  usually  small,  and  the  vagina  narrow,  absent, 
or  septate.  The  single  horn  may  also  be  solid  or 
partly  excavated. 

The  concomitant  defects  noted  are,  absence  of  the 
fallopian  tube,  round  and  broad  ligament  on  the  de- . 
ficient  side,,  as  well  as  the  corresponding  ureter  and 
kidney. 

Only  half  of  the  bladder  may  be  developed,  while 
the  ovaries,  when  present,  are  rudimentary. 

A  patient  with  a  uterus  unicornis  commonly  gives 
a  history  of  amenorrhea,  but  it  is  well  to  bear  in 
mind  that  menstruation  and  fecundation  have  oc- 
curred. Gestation  in  such  a  rudimentary  uterine 
horn  is  practically  an  ectopic  gestation,  with  all  of  its 
attendant  dangers  and  indications. 

The  uterus  didelphys,  diductus,  or  separatus, 
exhibits  the  maximum  degree  of  separation  between 
its  two  laterally  placed  halves,  which  normally  fuse 
into  the  single  viscus.  There  appear  to  be  two  single 
uteri  lying  side  by  side,  each,  however,  possessing 
unl}-  one  ovary,  tube,  and  round  ligament. 

There  may  also  be  complete  or  incomplete  dupli- 
cation of  the  vagina,  or  this  canal  may  be  single. 

The  two  uteri  are  rarely  of  equal  dimensions,  and 
one  of  them  may  be  imperforate — a  condition  giving 
rise  to  h^ematometra  at  puberty. 

Xot  uncommonly  this  uterine  malformation  is  as- 
sociated with  deformities  of  neighboring  parts,  such 
as  ectopia  vesicae  and  atresia  ani. 


CONGENITAL    MALFORMATIONS. 


283 


Since  it  is  impossible  to  differentiate  cases  of 
uterus  didelphys  from  the  more  frequent  uterus 
bicornis,  the  two  will  be  considered  together. 

Uterus  bicornis  denotes  the  condition  in  which 
the  two  halves  or  horns  are  not  entirely  separate,  as 
in  the  didelphous  organ,  but  are  united  more  or  less 
intimately  at  their  lower  end,  that  is,  in  the  region 
of  the  cervix  or  lower  part  of  the  corpus  uteri. 


Fig.  133. — Double  uterus  (uterus  didelphys).  a,  Right  cavity; 
b,  left  cavity;  c,  right  ovary;  d,  right  round  ligament;  e,  left  round 
ligament;  f,  left  tube;  g,  left  vaginal  portion;  h,  right  vaginal 
portion;  i,  right  vagina;  j,  left  vagina;  k,  partition  between  the  two 
vaginae.     (Mann.) 

The  mid-portions  of  Miiller's  ducts  had  evidently 
begun  to  fuse,  but  coalescence  ceased  short  of  the 
normal  limits,  and  a  uterus  is  produced  exhibiting 
clear  external  evidences  of  its  two-horned  origin. 

The  bicornate  uterus  is  the  connecting  link  be- 
tween the  uterus  didelphys,  which  presents  two  un- 
united halves,  and  the  uterus  septus  or  bilocularis, 
in  which  outwardly  the  organ  gives  no  indication  of 
duplicity. 


284 


GYNECOPLASTIC    TECHNOLOGY. 


The  uterus  bicornis  also  shows  all  possible  tran- 
sitions from  the  form  in  which  the  two  horns  are 
fused  in  the  cervical  area  only  to  that  in  which  the 
malformation  is  merely  indicated  by  a  shallow  de- 
pression or  notch  at  the  fundus. 


Fig.  134. — Case  of  bicornate  uterus,  with  carcinoma  of  both 
ovaries.  Septum  seen  running  down  to  the  single  cervical  canal. 
The  depression  at  the  fundus  is  characteristic. 

The  two  horns  may  be  of  equal  size,  or  one,  being 
retarded  in  development,  approximates  to  the  type  of 
uterus  unicornis. 

The  extent  of  bifurcation  varies  greatly.  In  the 
most  marked,  the  two  segments  present  a  considera- 
ble interval  superiorly,  bridged  by  a  band  or  frenum 
passing   from  the  bladder   to   the   rectum.      In   less 


CONGENITAL   MALFORMATIONS. 


285 


evident  cases  the  horns  he  close  together,  Init  are  not 
united.  The  cervix  may  1)e  l)road  and  large,  showing 
a  double  orifice  (uterus  bicornis  duplex;  septus  or  bi- 
cameratus);  it  may  be  double,  with  but  one  orifice, 
or  entirelv  normal. 


Fig.  135. — Left  tube,  ovary  and  uterine  nodule.  Tube  and  ovary 
normal  in  size.  The  membrane  below,  with  parallel  folds,  occupies 
the  position  of  the  uterine  body  and  upper  vagina.  Natural  size. 
(Kelly.) 


The  vagina  may  be  septate^  subseptate,  or  single, 
the  external  genitalia  usually  presenting  a  normal 
appearance. 

The  menstrual  function  may  be  variously  affected 
by  the  presence  of  a  didelphous  or  bicornate  uterus. 


286 


GYNECOPLASTIC  TECHNOLOGY. 


Fig.  136. — Case  of  double  uterus,  double  vagina  and  planiform 
fundus.  The  uterine  cavities  are  shown  in  double  lines.  Natural 
size.     (Kelly.) 


CONGENITAL    MALFORMATIONS.  287 

Menstruation  may  occur  every  two  weeks,  every 
month,  or  once  in  every  two  niontlis.  In  the  first  in- 
stance, the  menstrual  flow  comes  from  each  uterine 
cavity  alternately  every  two  weeks,  there  being  no 
coincidence  of  function ;  each  side  menstruates  inde- 
pendent of  the  other.  In  the  second  case,  both  sides 
menstruate  simultaneously,  or  each  side  functionates 
alternately  every  other  month.  In  the  third  instance, 
there  is  a  bimonthly  flow  from  one  half,  whilst  on 
the  other  side  there  is  an  imperforate  condition  of 
the  horn,  vagina,  or  hymen  which  obstructs  the 
egress  of  the  discharge. 

Pregnancy  may  occur  in  one  horn,  and  menstrua- 
tion from  the  other — a  circumstance  which  possibly 
accounts  for  the  continuance  of  menstruation  during 
gestation  in  many  unrecognized  cases. 

Decidua  may  form  in  the  empty  horn  or  each 
horn  may  harbor  an  ovum,  pregnancy  occurring  in 
both  horns  simultaneously  or  at  diflferent  but  not  far 
distant  dates,  thus  explaining  some  instances  of 
anomalous  superfetation.  The  bicornate  uterus  may 
abort  from  one  horn,  foetation  going  to  full  term  in 
the  other.  When,  as  sometimes  happens,  the  preg- 
nant horn  is  obstructed  by  a  septum,  gestation  be- 
comes practically  extra-uterine.  Even  in  cases  in 
which  there  is  no  unilateral  atresia,  rupture  of  the 
uterus,  or  of  the  septum  between  its  horns,  may 
occur  (see  Fig.  137). 

Uterus  Foctalis. — The  anatomical  uterine  charac- 
ters normal  to  the  foetus  may  persist  as  an  abnor- 
mality in  the  adult.  The  cervix  is  longer  than  the 
corpus;  its  walls  are  thick,  while  those  of  the  corpus 


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CONGENITAL   MALFORMATIONS.  289 

arc   thin.      It   is   conical   in   shape,   with   a   so-called 
"pin-hole  os." 

The  whole  organ  is  cylindrical  in  form  and  small 
in  size,  the  length  of  its  cavity  rarely  exceeding  i]^ 
inches.  The  term  "infantile  uterus"  is  practically 
synonymous  with  foetal  uterus.  The  endometrium  is 
poorly  developed,  and  may  present  an  absence  of 
utricular  glands. 

The  vagina  is  short,  especially  its  anterior  wall, 
usually  narrow,  but  may  be  normal.  Ovaries,  tubes, 
and  external  genitalia  are  infantile  in  contour,  and 
deficient  in  function. 

AA'ith  a  uterus  fetalis  there  is  usually  amenor- 
rhea, or  at  most  a  scant,  irregular,  and  painful  men- 
struation. Sterility  is  constant.  Chlorosis,  a  small 
heart,  small  aorta,  and  general  hypoplasia  of  the 
vascular  system  are  frequent  concomitants. 

All  attempts  at  treatment  of  the  fetal  uterus  are 
futile,  while  in  the  pubescent  uterus  a  small  propor- 
tion attain  some  approximation  to  normal  functions 
later  in  adult  life. 

Uterine  Atresia  and  Stenosis. — The  uterus  may 
be  congenitally  imperforate — an  anomaly  w^hich  finds 
its  explanation  in  the  originally  solid  condition  of 
Miiller's  ducts,  from  which  it  is  developed.  Uterine 
atresia  is  not  so  much  an  independent  malformation 
as  a  complication  of  other  defects.  The  whole  cervix 
may  be  solid  or  present  a  septum  at  the  external  or 
internal  os.  At  puberty  hematometra  may  develop, 
which  may  be  unilateral  in  bicornate  cases. 

The  symptoms  of  uterine  atresia  are  mainly  those 
of  hematometra,  and  as  these  are  also  encountered 

19 


290  GYNECOPLASTIC   TECHNOLOGY. 

in  vaginal  atresia,  their  further  consideration  will  be 
deferred  to  the  chapters  on  the  latter  anomaly. 

Infantile  or  Congenital  Anteflexion  is  in  reality 
an  anteflexion  of  the  cervix  only,  which  usually  is 
conical  in  shape  with  a  minute  external  orifice,  and 
foreshortened  anterior  vaginal  wall. 

Dysmenorrhea  and  sterility  are  the  rule,  the 
more  direct  cause,  however,  being  a  chronic  endocer- 
vicitis,  to  which  these  cervices  are  especially  prone. 


CHAPTER  XXVI. 

Malformation  of  the  Vagina  and  Vulva. 

Vaginal  malformations  present  many  charac- 
ters in  common  with  those  of  the  uterus — a  circum- 
stance readily  understood  when  we  recall  that  both 
vagina  and  uterus  are  derivatives  of  the  Miillerian 
ducts. 

Moreover,  vaginal  and  uterine  defects  frequently 
coexist,  and  in  many  instances  combine  to  establish 
a  clinical  complex. 

While  abnormal  communications  between  the 
uterus  and  contiguous  viscera  are  rare,  the  congenital 
fistulas  between  the  vagina  and  its  neighboring 
organs  are  relatively  frequent. 

Double  Vagina (YRgins.  septa). — A  double  vagina 
in  the  literal  sense  can  only  be  said  to  exist  in  cer- 
tain double  terata,  such  as  the  pygopagous  twins; 
but  it  has  become  customary  to  apply  the  term  to 
cases  in  which  the  two  Miillerian  ducts,  which  nor- 
mally fuse  into  one  canal,  have  remained  separate, 
the  residual  septum  persisting  along  a  part  or  the 
entire  extent  of  its  vaginal  course. 

In  the  great  majority  of  cases  this  septum  runs 
anteroposterior^,  and  the  vaginae  are  situated  later- 
ally. More  rarely  it  extends  transversely,  when  the 
vaginal  canals  lie  in  front  of  one  another.  In  the 
latter  instance,  the  two  unfused  ducts  must  have 
undergone  a  partial  rotation. 

(291) 


292  GYNECOPLASTIC   TECHNOLOGY. 

The  two  canals  are  never  perfectly  symmetrical 
in  position  or  calibre.  Ordinarily  the  left  lies  a  little 
in  front  of  the  right.  The  septum  is  composed  of 
muscular  tissue  covered  by  mucous  membrane,  and 
has  the  consistency  of  the  rectovaginal  septum.  It 
varies,  however,  in  thickness,  and  may  be  perforated. 
It  may  be  absent  at  the  introitus,  and  present  at  any 
point  above,  and  z'ice  versa.  Its  remnant  may  be  in- 
dicated by  a  ridge  or  cock's-comb  elevation  on  the 
vaginal  wall.  In  the  majority  of  cases  the  uterus  is 
double,  i.e.,  didelphous,  bicornate,  or  septate,  present- 
ing one  cervical  orifice  in  each  vaginal  compartment. 

In  a  few  recorded  cases  the  uterus  was  single,  its 
cervix  projecting  into  one  or  other  of  the  vaginal 
lumina.  In  atresia  of  one  or  both  vaginal  tracts,  uni- 
lateral or  bilateral  hematocolpos  will  develop  in  adult 
life. 

It  is  claimed  that  during  pregnancy  the  septum 
may  be  absorbed,  but  should  it  persist  to  term,  de- 
livery may  be  impeded.  When  one  canal  is  imper- 
forate, the  condition  may  simulate  a  vaginal  cyst. 

Atresia  Vagiuce  implies  any  defect  of  the  vaginal 
canal,  from  its  complete  or  partial  absence  to  a  simple 
membranous  obstruction  or  perforated  diaphragm 
existing  at  some  part  of  its  lumen. 

When  the  upper  two-thirds  of  the  vagina  are  oc- 
cluded, the  patulous  lower  third  is  not  vaginal  in 
nature,  but  represents  an  enlarged  vestibular  canal, 
the  vestige  of  the  sinus  urogenitalis.  Through  the 
arrest  in  the  downward  progress  of  the  Miillerian 
ducts,  the  vestibular  canal  has  retained  its  early 
dimensions,  its  depth  being  increased  by  coital 
attempts.     When  the  central  vaginal  zone  is  atretic. 


MALFORMATION  OF  VAGINA  AND  VULVA.  293 

it  may  be  assumed  thai  the  n])])er  canal  is  Miillerian 
or  truly  vaginal,  while  the  lower  part  is  vestibular. 

The  uterus,  adnexa,  and  vulva  may  be  normal, 
rudimentary  or  absent.  If  the  uterus  and  ovaries  are 
present,  the  condition  reveals  itself  at  puberty  by 
hematocolpos,  hematometra,  and  hematosalpinx. 

The  surgical  indications  will  be  entirely  domin- 
ated by  the  extent  and  position  of  the  defect,  by  the 
presence  or  absence  of  the  internal  generative  organs, 
or  by  the  accumulation  of  retained  menstrual  blood. 

Patients  with  extensive  defects  of  the  vagina  and 
uterus,  in  whom  severe  menstrual  molimina  indicate 
the  presence  of  functioning  ovaries,  may  demand 
oophorectomy  for  relief. 

Hematocolpos  and  hematometra  invariably  call 
for  operative  intervention.  It  is  not  correct  to  leave 
such  blood  accumulations  to  nature.  Spontaneous 
rupture,  even  when  it  occurs  through  the  vaginal 
tract,  is  seldom  safe  in  its  immediate,  or  satisfactory 
in  its  ultimate,  results. 

Dyspareunia,  as  such,  in  the  absence  of  uterus 
and  ovaries,  and  without  other  subjective  manifesta- 
tions, is  a  questionable  indication  for  the  operative 
construction  of  an  artificial  vagina — a  difficult  and 
dangerous  procedure,  the  results  rarely  justifying 
the  means  especially  in  very  extensive  cases. 

Abnormal  Coinmunications  of  the  Vagina. — The 
vagina  may  open  into  the  rectum  through  a  develop- 
mental defect  of  the  rectovaginal  septum,  or  it  may 
communicate  by  a  small  orifice  with  the  urethra. 

Most  of  the  abnormal  clefts  between  the  vaginal 
canal  and  its  contiguous  viscera  are  in  reality  vulvar 


294 


GYNECOPLASTIC    TECHNOLOGY. 


A 


B 


Fig.  138. — Development  of  the  external  genitals  (after  Ecker- 
Ziegler  models).  A,  Indifferent  stage  (eighth  week)  :  gt,  genital 
tubercle ;  gr,  genital  ridge ;  gf,  genital  fold ;  gg,  genital  groove.  B, 
Female  type:  cl,  clitoris;  /.  m<ij,  labia  majora;  v,  vestibule;  /.  min, 
labia  minora ;  vag,  vagina ;  p,  perineum.  C,  Male  type :  gp,  glans 
penis;  pr,  prepuce;  r,  raphe;  s,  scrotum. 


MALFORMATION  OF  VAGINA  AND  VULVA.  295 

anomalies,  due  to  the  persistence  of  the  sinus  uro- 
genitahs  or  of  embryonic  cloaca. 

Malformations  of  tJie  Vulva. — Atresis  vulvae 
superficialis  is  applied  to  the  condition  in  which  ad- 
hesions of  the  labia  majora  or  minora  obliterate  the 
normal  vulvar  cleft. 

Ordinarily  the  occlusion  is  not  complete,  a  small 
orifice  existing  near  the  root  of  the  clitoris  through 
which  urine  and  menstrual  fluids  escape.  The  ano- 
maly may  be  present  at  birth  or  may  develop  in 
infancy.  In  both  cases  it  is  due  to  adhesive 
vulvitis. 

In  early  life  there  may  be  discomfort  in  micturi- 
tion. After  puberty  the  menstrual  flow  may  be  im- 
peded, but  hematocolpos  does  not  develop.  Coital 
penetration  may  be  impossible,  but  not  impregnation. 

Abnormal  Coinrmmications  of  the  Vulva. — There 
is  a  phase  in  the  developmental  period,  when  the 
allantois  (bladder),  Miillerian  ducts  (vagina),  and 
rectum  all  open  into  a  common  cavity,  which  drains 
to  the  surface  of  the  body,  and  is  called  the  cloaca. 
Normally,  this  condition  is  transitory.  When  it  per- 
sists and  becomes  permanent,  the  anomaly  known  as 
atresia  anivaginalis  or  vulvar  anus  results. 

Atresia  Ani  Vaginalis  (anus  vulvalis). — The 
term  ''persistent  cloaca"  is  better  adapted  to  this 
condition  than  the  cumbersome,  inaccurate  atresia 
anivaginalis,  in  which  the  normal  anus  is  apparently 
absent,  the  rectum  emptying  through  the  vagina  or 
vulva,  the  feces  escaping  through  an  opening  either 
in  the  neighborhood  of  the  vestibule  or  in  that  of  the 
posterior  commissure. 


296 


GYNECOPLASTIC   TECHXOLOGY. 


Hypospadias  (persistent  urogenital  sinus). — In 
one  sense  it  is  incorrect  to  speak  of  hypospadias  in 
the  woman  as  an  anomaly.  There  is,  however,  a 
malformation  of  her  external  genitalia  to  which  this 
designation  has  been  applied,  presenting  a  persist- 
ence of  the  urogenital  sinus.  The  urethra  appears 
to  open  into  the  vagina,  but  what  is  regarded  as 
vagina  is  in  reality  sinus  urogenitalis. 


tj^jij-*- 


Fig.  139. — Anus  vulvalis.     (After  Dwight.) 


Through  a  common  opening  at  the  base  of  the 
clitoris,  which  latter  is  frequently  hypertrophied,  both 
the  urine  and  menstrual  blood  escape.  The  peri- 
neum and  anus  are  normal.  Thus  the  condition  dif- 
fers from  the  persistent  cloaca  of  atresia  ani- 
vaginalis. 

Pozzi  describes  two  varieties,  differing  in  degree. 
In  the  one  of  minor  degree,  the  vestibular  canal  is 
long  and  narrow,  with  its  urethral  opening  high  up 
in  the  vagina.     This  type  is  frequenth'  accompanied 


M/VLFORMATION  OF  VAGINA  AND  VULVA. 


297 


by  hypertrophy  of  the  cHtoris,   thus   creating"  some 
doubt  at  times  as  to  the  sex  of  the  individual. 

In  the  second  degree,  which  may  be  called  hypo- 
spadia proper,  the  urogenital  canal  has  disappeared, 


Fig.  140. — Pseudohermaphroditism,  perineoscrotal  hypospadias, 
{Aii&r  Poszi.)  g,  glans;  b,  frenum;  mu,  meatus  urinarius ;  ov, 
vulvar  orifice;  hy,  hymen;  f,  fourchette;  pi,  labia  minora;  gl,  labia 
majora. 


but  the  lower  part  of  the  allantois,  which  should  have 
developed  into  the  urethral  canal,  has  been  included 
in  the  formation  of  the  bladder.  There  is  thus  an 
absence  of  the  urethra,  while  the  vagina  and  bladder 


298  GYXECOPLASTIC   TECHNOLOGY. 

Open  together  into  the  vestibular  canal,  with  incon- 
tinence of  urine  as  a  result. 

Epispadias  is  observed  as  a  simple  defect  in  the 
upper  urethral  wall,  or  a  part  of  a  similar  defect  of 
the  bladder,  abdominal  wall,  and  pubic  bones,  i.e., 
ectopia  vesicse.  In  the  former  condition  the  urethra 
is  seen  as  an  open  groove  or  gutter  passing  upward 
in  the  position  of  the  vestibule,  and  disappearing  un- 
der the  symphysis  pubis,  to  terminate  in  the  bladder 
or  into  an  upper  normal  part  of  the  urethra.  On 
either  side  of  the  groove  lies  one-half  of  the  bifid 
clitoris,  continuous  with  its  apertinent  labium  minus. 
CSee  chapter  on  Exstrophy  of  the  Bladder.) 

The  labia  majora  may  unite  normally  or  diverge. 
Intermediate  types  between  these  two  are  observed. 

The  most  important  clinical  manifestation  of  un- 
complicated epispadias  is  incontinence  of  urine. 
The  incontinence  is  not  usually  absolute,  but  any 
sudden  exertion,  change  of  position,  coughing  or 
sneezing,  is  accompanied  by  a  gush  of  urine  from 
the  bladder,  which  is  usually  abnormally  small  in 
size. 

Malfoniiafions  of  the  Hymen. — Most  of  the  hy- 
menal malformations  are  clinically  unimportant. 
There  is  as  yet  no  general  acceptance  of  any  one 
theory  as  to  the  mode  of  its  development,  some  as- 
serting that  it  is  vaginal,  others  that  it  is  vulvar  in 
origin.  On  either  hypothesis,  it  is  simply  a  develop- 
mental remnant,  not  a  ''fixed  organ,"  and,  like  all 
other  remnants  of  a  similar  nature,  presents  innu- 
merable anomalies  of  structure,  form,  and  position. 

Cases  of  double  hymen  which  have  been  reported 
are  probably  errors  of  interpretation,  the  upper  sup- 


MALFORMATION  OF  VAGhXA  AND  VULVA. 


299 


plementary  membrane  usually  consisting  of  a  per- 
forated diaphragmatic  septum  in  the  vaginal  canal, 
a  little  above  the  normal  hymen. 

Two  or  three  of  such  septa  may  exist,  some 
doubtless  due  to  adhesions  between  the  walls  of  the 
fetal  vagina. 

Atresia  Hynienalis  (imperforate  hymen)  is  not 
as  common  as  the  number  of  reported  cases  would 


Fig.  141. — Agglutination  of  the  labia  in  a  little  girl.  There  is  a 
distinct  raphe  in  the  middle,  with  a  translucent,  slightly  furrowed 
membrane  on  both  sides,  which  conceals  the  urethra  and  the  hymen. 

indicate.  In  the  majority  of  the  cases  the  supposed 
hymenal  diaphragm  is  in  reality  the  blind  end  of  the 
Miillerian  vagina. 

It  is  often  possible  to  locate  the  normally  per- 
forate hymen,  displaced  and  covered  by  the  bulging 
of  the  vaginal  saccular  protrusion.  Strictly  speak- 
ing, cases  of  hymenal  atresia  are  often  instances  of 
simple  vaginal  atresia.     In  other  cases,  adhesions  of 


300  GYNECOPLASTIC   TECHNOLOGY. 

the  labia  minora  give  rise  to  an  appearance  resemb- 
ling atresia  of  the  hymen,  and  it  is  only  after  divi- 
sion of  the  labial  attachment  that  the  true  normal 
hymen  is  found  beneath.  The  clinical  results  in  all 
of  these  cases  is  the  same,  namely,  retention  of 
mucus  in  infancy,  and  menstrual  blood  in  the  adult. 

Pseiidohermaphroditism. — The  exact  meaning  of 
the  word  "hermaphrodite,"  as  applied  to  the  human 
subject,  has  undergone  a  change.  Whilst  the  older 
writers  applied  the  term  to  individuals  whom  they 
regarded  as  possessing  the  organs  of  both  sexes,  in 
an  anatomical  and  physiological  sense,  modern  au- 
thors use  the  name  rather  to  indicate  subjects  whose 
true  sex  is  doubtful.  Malformations  of  the  genital 
organs,  giving  rise  to  doubt  as  to  the  true  sex  of 
the  individual,  have  attracted  the  attention  of  ob- 
servers from  the  earliest  periods  of  the  world's  his- 
tory, and  records  of  such  cases  have  been  found  on 
the  brick  tablets  of  the  ancient  Chaldean  libraries. 
In  Rome,  individuals  of  doubtful  sex  were  destroyed. 
In  the  East,  on  the  other  hand,  there  is  reason  to  be- 
lieve that  they  were  deified.  According  to  the  Tal- 
mud, Abraham  was  a  hermaphrodite,  and  so,  ac- 
cording to  many  authors,  was  Adam. 

In  one  sense,  the  human  enibr3^o  at  a  certain 
period  of  its  existence  may  be  regarded  as  herma- 
phrodite. There  is  a  stage  in  development  when  it 
is  impossible  to  state  whether  the  sexual  gland  will 
become  an  ovary  or  testicle;  whether  the  Miillerian 
or  the  Wolffian  ducts  will  atrophy;  whether  the  geni- 
tal tubercle  will  become  a  penis  or  a  clitoris.  The 
embryo  is  then,   so  far  as  is  known,   potentially  of 


MALFORMATION  OF  VAGINA  AND  VULVA.  301 

either  sex,  and  awaits  the  action  of  some  force  to 
determine  which  sex  is  to  predominate. 

It  is  easy  to  understand  how  morhid  influences, 
brought  to  bear  upon  the  embryo  at  or  about  the 
time  when  it  is  passing  from  its  sexually  indilTerent 
stage  into  one  of  differentiation,  may  so  upset  the 
normal  process  of  development  as  to  produce  an  in- 
dividual with,  for  example,  testicles  and  a  uterus. 
It  is,  however,  a  matter  of  great  difficulty  to  imagine 
a  condition  of  affairs  which  would  give  rise  to  the 
presence  of  a  testicle  and  an  ovary  on  the  same  side; 
for,  so  far  as  is  known,  the  sexual  gland  may  be- 
come either  a  testicle  or  an  ovary,  but  not  both.  In 
the  Miillerian  and  Wolffian  ducts,  on  the  other  hand, 
we  have  to  do  with  two  sets  of  structures,  one  of 
which  normally  atrophies,  and  the  other  develops; 
but  abnormally  both  may  persist  in  a  more  or  less 
fully  formed  condition.  As  a  matter  of  fact,  it  is 
very  doubtful  whether  a  genuine  case  of  the  coexist- 
ence of  testicles  and  ovaries  in  the  human  subject 
has  ever  been  reported;  whilst  instances  of  pseudo- 
hermaphroditism, as  they  have  been  called,  are  far 
from  rare.  Still,  it  is  never  safe  to  say  that  the  oc- 
currence of  any  particular  teratological  combination 
is  impossible;  and  if  we  bear  in  mind  that  true  her- 
maphroditism has  been  met  with  in  fish,  amphibians, 
and  even  in  the  goat  and  pig,  it  may  be  that  some 
observer  will  yet  record  an  undoubted  case  in  the 
human  subject. 

Cases  of  pseudohermaphroditism  are  not  uncom- 
mon. In  many  of  them  the  dubiety  as  regards  sex 
is  due  to  the  existence  of  one  or  other  of  the  anoma- 
lies of  the  female  external  genital  organs,   already 


302 


GYNECOPLASTIC    TECHNOLOGY. 
A  B 


Fig.  142. — Atresia  at  the  vulva  first  causes  distention  of  the 
vagina,  producing  hematocolpos.  B,  Hematotrachelos  has  followed 
hematocolpos.  C,  Hematometra  has  follow^ed  hematotrachelos.  D, 
In  addition  to  C  there  is  added  hematosalpinx.     (Sulton  and  Giles.) 


MALFORMATION  OF  VAGINA  AND  VULVA. 
E  F  G 


303 


Fig.  143. — E,  Atresia  in  the  vagina,  midway  between  the  vulva 
and  the  os  externum,  causing  hematocolpos  on  the  upper  half  of  the 
vagina.  F,  Same  as  E,  except  that  distention  of  the  whole  uterus 
has  followed  the  partial  hematocolpos.  G,  Atresia  of  the  os  ex- 
ternum, producing  a  hematotrachelos.  Corpus  uteri  not  yet  dis- 
tended. H,  Atresia  of  the  os  internum,  producing  hematometra. 
Fallopian  tubes  may  become  distended  later.  I,  Atresia  of  the  vulva 
on  one  side  of  a  double  uterus  and  vagina,  causing  a  hematocolpos 
on  the  affected  side.     (Sulioii  and  Giles.) 


304  GYNECOPLASTIC   TECHNOLOGY. 

described.  In  many  more,  however,  we  have  to  deal 
with  malformations  of  the  penis  and  scrotum,  which 
have  given  to  the  external  parts  a  somewhat  femi- 
nine appearance.  In  the  former  group  of  cases  the 
ovaries  are  present,  whatever  may  be  the  condition 
of  the  other  organs,  and  the  individual  is  therefore 
really  a  female  in  the  state  known  as  pseudoherma- 
phroditisnms  femininus,  or  gynandry.  In  the  latter 
group,  the  subject,  by  the  possession  of  the  testicles, 
is  a  male,  however  closely  he  may  approach  the  other 
sex  in  appearance — a  state  known  as  pseudoherma- 
phroditismus  masculinus,  or  androgyny.  Individ- 
uals of  the  second  kind  are  more  numerous  than 
those  of  the  first.  Each  of  these  two  varieties  has 
been  subdivided  into  three  groups — internus,  exter- 
nus,  and  completus.  Thus,  in  a  case  of  pseudoherma- 
phroditismus  masculinus  internus  there  are  testicles 
in  association  with  external  genitals  of  the  male 
type,  and  a  uterus,  vagina,  and  even  tubes.  In  pseu- 
dohermaphroditismus  masculinus  externus  there  are 
also  testicles,  but  the  external  genitals  and  the  build 
of  the  body  are  feminine.  Again,  in  pseudoherma- 
phroditismus  masculinus  completus  seu  externus  et 
internus  there  are  testicles,  but  there  is  also  a 
uterus  with  tubes,  and  the  external  organs  ap- 
proach more  or  less  closely  to  the  female  form.  In 
the  same  way,  in  the  three  varieties  of  feminine 
pseudohermaphroditism  there  are  always  ovaries; 
but  in  the  internal  type  there  are  also  distinct  traces 
of  the  Wolffian  ducts;  in  the  external  type  the  ex- 
ternal genitals  are  of  the  male  form ;  and  in  the  com- 
plete type  the  external  organs  are  masculine,  and  the 
Wolffian  ducts  and  prostate  gland  are  present.     The 


MALFORMATION  OF  VAGINA  AND  VULVA. 


305 


enumeration  of  these  varieties  will  have  given  some 
idea  of  the  morbid  anatomy  of  pseudohermaphrodi- 
tism. At  the  same  time  it  must  be  borne  in  mind  that 
some  of  them  are  very  rare.  One  of  them,  on  the 
other  hand — pseudohermaphroditismus  masculinus 
externus — is,  comparatively  speaking,  very  common. 
One  of  the  most  usual  arrangements  of  parts  to 
which  the  name  of  feminine  pseudohermaphroditism 


Fig.  144. — Feminine  pseudohermaphroditism. 


is  given  is  that  in  which  a  woman  presents  an  adhe- 
sion of  the  labia  along  w^ith  hypertrophy  of  the  clit- 
oris. When,  also,  there  is  a  labial  ovarian  hernia  on 
one  or  both  sides,  and  a  development  of  hair  on  the 
face,  the  resemblance  to  the  male — at  any  rate,  to 
the  hypospadiac  male — becomes  very  striking.  The 
vulva,  however,  may  be  normal,  and  the  subject 
show  simply  an  enlarged  clitoris,  a  beard,  and  a  mas- 
culine arrangement  of  the  pubic  hair. 

20 


306  GYXECOPLASTIC    TECHNOLOGY. 

Xon-descent  of  the  testicles  in  the  male  gives 
origin  to  one  variety  of  androgyny.  Such  men  are 
often  the  subjects  of  gynaecomastia  (enlargement  of 
the  breasts) ;  and  since  also  the  penis,  although  per- 
forate, is  sometimes  small,  and  the  sexual  functions 
poorly  developed  (infantilism),  it  is  easy  to  under- 
stand how  doubts  as  to  their  virility  may  arise.  A 
more  common  type  of  androgyny,  however,  is  that 
caused  by  the  existence  of  scrotal  hypospadias.  In 
this  case  the  resemblance  to  the  female  type  of  exter- 
nal genitals  is  very  strong,  for  there  is  a  small  imper- 
forate penis  often  fixed  in  position  under  the  S3^mphy- 
sis  by  adhesions ;  the  urethra  opens  externally  near  the 
penile  root  and  below  it  is  a  sort  of  vulvar  aperture 
or  vestibular  canal  which  may  even  be  of  some  depth, 
and  may  be  guarded  by  a  hymen.  The  external 
genitals  in  such  a  case  resemble,  as  Pozzi  graphically 
expresses  it,  those  of  an  embryo  seen  under  a  magni- 
fying glass.  When  it  is  also  borne  in  mind  that  the 
testicles  are  either  undescended  or  at  any  rate  atro- 
phic, and  that  the  individual  has  probably  been  mis- 
taken for  and  brought  up  as  a  girl,  and  has  thus 
acquired  feminine  habits,  it  is  easy  to  see  how  ex- 
tremely difficult  it  may  be  to  ascertain  the  real  sex. 
The  difficulty  may  be  still  further  increased  by  en- 
largement of  the  mamm^,  by  the  absence  of  hair  on 
the  face  and  chest,  and  by  the  occasional  discovery 
of  a  uterus,  although,  of  course,  ovaries  are  not  to 
be  detected.  Doubtless  most  of  the  cases  of  sup- 
posed true  hermaphroditism  have  been  really  hypo- 
spadiac  men. 

Cliuical  Features. — Whilst  in  the  histories  of 
pseudohermaphrodites  there  are  many  details  which 


MAIJ'OKMATKJN  OF  VAGINA  AND  VULVA.  307 

are  peculiar  to  each  case,  there  are  also  some  which 
are  practically  common  to  all.  ^fhe  error  in  the 
recognition  of  the  true  sex  of  the  individual  is 
usually  made  at  birth,  and  confirmed  at  baptism; 
and,  as  a  rule,  it  is  not  till  the  period  of  puberty 
is  reached  that  doubts  arise  as  to  the  accuracy 
of  the  declaration  at  birth.  In  the  case  of  male 
pseudohermaphrodites,  the  error  may  even  be  per- 
petuated, and  the  individual  be  married  as  a  woman, 
and  live  with  a  husband,  an  imperfect  form  of  coitus 
taking  place  per  urethram.  Usually,  however,  sus- 
picions begin  to  be  entertained  at  puberty  when,  in 
the  case  of  hypospadiac  males  brought  up  as  females, 
the  absence  of  the  menstrual  function  and  the  ap- 
pearance of  certain  secondary  sexual  characters 
proper  to  the  male  sex  give  rise  to  doubts.  At  the 
same  time,  it  must  be  borne  in  mind  that  even  in 
these  subjects  hemorrhage  simulating  the  menses 
may  take  place  from  the  urethra,  dilated  by  coitus, 
and  in  a  few  instances  a  real  catamenial  discharge 
from  a  uterus  has  been  noted. 

Further,  the  secondary  sexual  characters  cannot 
be  relied  upon;  for  mammary  enlargement,  rounded 
outlines,  a  broad  pelvis,  a  small  larynx,  and  a  femi- 
nine distribution  of  the  body-hair,  may  all  be  met 
with  in  male  pseudohermaphrodites,  while  the  secon- 
dary sexual  characters  of  the  male  may  coexist  wdth 
ovaries.  The  habits,  also,  and  the  feelings  and  de- 
sires of  the  subject,  will  depend  largely  on  the  sur- 
roundings in  early  life,  and  cannot  be  regarded  as 
diagnostic  of  the  sex. 

"The  treatment  of  such  cases  presents  many  puz- 
zling   problems.      Lawson    Tait's    rule,    that    every 


308  GYNECOPLASTIC   TECHNOLOGY. 

infant  about  whose  sex  there  is  doubt  should  be 
brought  up  as  a  male,  is  a  good  one ;  for  male  pseudo- 
hermaphrodites are  more  common  than  female;  indi- 
viduals reared  as  males  are  not  so  apt  to  enter  into 
marriage  in  ignorance  of  their  sexual  inability;  and 
there  is  less  danger  in  bringing  up  a  girl  among 
boys  than  a  boy  among  girls.  The  question  as  to 
the  advisability  of  surgical  interference  is  a  difficult 
one.  In  a  case  reported  by  Christopher  Martin,  the 
testicles  were  removed  from  an  individual  brought 
up  as  a  girl,  and  castration  was  followed  by  a  de- 
velopment of  the  breasts  and  pubic  hair;  while  Pean 
records  the  extraordinary  operative  history  of  an 
individual  whose  abdomen  was  first  opened  to  dis- 
cover the  sex,  then  an  artificial  vagina  was  made,  and 
finally  the  abdomen  was  again  opened  and  the  tubes 
and  ovaries  removed.  The  separation  of  the  adhe- 
rent labia  in  a  gynandrous  individual  is  a  minor  op- 
eration, which  may  be  undertaken  without  hesita- 
tion; but  it  is  doubtful  whether  we  are  justified  in 
removing  the  sexual  glands  in  any  case  of  pseudo- 
hermaphroditism" (J.  W.  Ballantyne). 


CHAPTER  XXVII. 

Operative  Correction  of  Congenital 
Malformations. 

The  clinical  range  of  congenital  anomalies,  as 
elucidated  in  the  preceding  chapters,  affords  a  very 
limited  scope  for  legitimate  operative  intervention, 
as  most  of  the  conditions  enumerated  are  obviously 
beyond  corrective  possibilities.  Surgical  plastic  can- 
not construct  organs  nor  create  functions ;  it  can  only 
aim  to  readjust  certain  defections  of  visceral  align- 
ment and  continuity  that  bar  or  impede  the  normal 
manifestation  of  their  latent  virility. 

The  phases  of  genital  maldevelopment  amenable 
to  operative  measures  are:  imperforate  hymen,  ste- 
nosis of  the  vaginal  introitus,  atresia  or  absence  of 
the  vagina,  and  ectopia  vesicae. 

Imperforate  Hymen. — Imperforate  hymen  and 
vaginal  atresia  are  rarely  noticed  before  puberty.  In 
some  instances  a  protrusion  of  the  septum  during 
violent  efforts  has  directed  attention  to  the  condition, 
while  in  others  a  collection  of  mucus  behind  the  sep- 
tum has  produced  a  fluctuating  protrusion  between 
the  labia.  Granwell  reports  the  case  of  an  infant, 
I  month  old,  with  a  tumor  filling  the  pelvis  and  lower 
abdomen  to  the  umbilicus.  The  vulva  and  perineum 
were  reddened  and  oedematous.  Urinary  retention 
was  at  first  suspected,  but  disproved  on  catheteriza- 
tion.    Incision  of  the  occluding  membrane  gave  vent 

(309) 


310 


GYNECOPLASTIC   TECHNOLOGY. 


to  a  small  amount  of  pus,  followed  by  about  400  mils 
of  yellow  fluid. 

Slight  epithelial  adhesions  between  the  mucous 
folds  immediately  behind  the  hymen  are  not  uncom- 
mon in  children,  and  may  be  mistaken  for  imperfo- 
rate hymen.  Spontaneous  rupture  may  occur.  In 
the  adult,  atresia  at  any  point  of  the  vulvovaginal 


Fig.  145. — Same  as  Fig.  141,  after  division  of  the  membrane. 
Urethra  and  hymen  exposed. 

tract,  is  followed  by  an  accumulation  of  menstrual 
fluid  above  the  obstructed  area.  If  the  atresia  in- 
volves only  the  hymen,  the  anterior  or  mid-portion 
of  the  vagina,  its  upper  part  becomes  distended, 
forming  a  hematocolpos. 

With  increasing  distention,  the  cervix  is  gradu- 
ally obliterated,  and  hematometra  and  hematosalpinx 
develop. 


OPERATIONS  FOR  MALFORMATIOXS.  311 

If  the  atresia  is  not  corrected  in  time,  serious 
consequences  may  ensue,  the  two  principal  dangers 
being  rupture  and  infection.  Spontaneous  rupture 
is  the  usual  sequel  of  the  distention,  and  may  occur 
either  externally  or  internally. 

In  external  rupture  the  vaginal  wall  gives  way, 
but  cases  of  perforation  through  the  base  of  the 
labium  ma  jus  and  the  gluteal  region  are  on  record. 

External  rupture  is  sometimes  followed  by  com- 
plete recovery;  but  in  many  cases  the  distended 
cavity  became  infected,  with  lethal  result  from  gen- 
eral sepsis. 

Internal  rupture  is  more  frequent,  and  perfor- 
ates the  vaginal  or  uterine  wall.  The  resulting 
hematoma  may  be  discharged  through  the  rectum 
or  into  the  bladder.  Recovery  may  follow  either,  but 
the  spontaneous  vent  is  usually  inadequate,  pro- 
ducing a  recurrence  of  the  condition,  or  a  persistent 
fistular  communication.  The  gravest  of  all  possi- 
bilities is  an  intra-abdominal  rupture  of  a  hemato- 
salpinx, with  consequent  peritonitis. 

The  treatment  for  imperforate  hymen  is,  crucial 
incision  of  the  obstructive  portion,  with  excision  of 
its  central  area.  The  cut  edges  should  be  sutured 
with  catgut  to  check  bleeding,  and  the  cavity  above 
gently  irrigated  with  warm  normal  saline  solution. 
Small  adherent  particles  of  inspissated  blood  invari- 
ably remain,  and  favor  the  rapid  multiplication  of 
any  infecting  organisms  that  may  find  entrance. 
The  great  danger  of  sepsis,  particularly  when  the 
blood-distended  cavity  involves  the  uterus,  demands 
the  most  rigid  aseptic  precautions  throughout  the 
operative  and  convalescent  stage. 


312 


GYNECOPLASTIC   TECHNOLOGY, 


In  some  cases  the  vaginal  introitus  is  inadequate, 
not  as  the  result  of  any  hymenal  obstruction,  but  due 
to  a  congenital  narrowing  or  hypercontractility  of 
the  levator  ani,  with  consequent  vaginismus  and 
dyspareunia. 

If  such  narrowing  cannot  be  relieved  by  repeated 
dilatation,  it  may  be  permanently  overcome  by  di- 
viding the  upper  third  or  half  of  the  perineum  in  an 


Fig.  146. — Widening  the  vaginal  opening  for  dyspareunia.  I, 
The  perineum  is  to  be  excised  as  indicated  by  the  dotted  Hne,  one- 
half  or  two-thirds  of  the  distance  to  the  rectum.  II,  The  wound 
has  been  spread  open,  and  is  being  closed  so  that  its  length  will 
lie  transversely.  Ill,  The  operation  completed.  After  healing,  the 
vaginal  opening  will  be  permanently  enlarged,  as  indicated.  There 
is  a  marked  tendency  of  the  approximated  edges  to^  pull  apart.  If 
catgut  alone  is  used,  it  should  be  well  chromicised  (40  days). 
Even  that  failed  to  maintain  complete  approximation  in  some  of 
the  author's  cases.  It  is  advisable  to  put  in  two  or  three  tension 
sutures  of  silkworm  gut,  or  close  entirely  with  same.     (Crossen.) 


anteroposterior  direction,  converting  this  longitudi- 
nal incision  into  a  transverse  slit  by  proper  traction, 
and  suturing  it  in  this  position,  for  which  purpose 
silkworm  gut  or  40-day  chromic  gut  is  used. 


OPERATIONS  FOR  MALFORMATIONS.  313 

Simple  membranous  atresia  of  the  vagina  is 
treated  like  an  imperforate  hymen,  namely,  by  in- 
cision and  excision  of  the  obstructing  tissue  under 
aseptic  precautions.  In  these  conditions  it  is  essen- 
tial to  differentiate  simple  atresia  from  the  condition 
in  which  the  upper  vaginal  canal  is  entirely  absent; 
the  distinguishing  feature  between  the  two  is  the 
presence  of  fluid  accumulation  above  the  obstruction. 

In  atresia  of  the  vaginal  vault  and  cervix,  sur- 
gery is  of  very  questionable  utility.  The  technical 
difficulties  and  dangers,  owing  to  the  usual  necessity 
of  attack  both  from  above  and  below,  are  not  war- 
ranted by  the  precarious  functional  results  in  the  few 
successful  cases  thus  far  reported. 

Absence  of  the  Vagina. — Congenital  absence  of 
the  vagina  and  complete  atresia  are  at  times  difficult 
to  differentiate,  but  the  question  is  not  of  surgical 
importance,  as  both  conditions  are  usually  accom- 
panied by  other  developmental  defects  of  a  grade  to 
exclude  all  corrective  intervention.  Moreover,  if  a 
well-developed  uterus  should  be  present,  the  opera- 
tive course  would  be  practically  similar  in  either  case. 
The  structural  difference  between  the  two  conditions 
is  the  presence  of  a  fibromuscular  band  between  the 
rectum  and  bladder  in  atresia,  while  in  total  absence 
of  the  vagina  the  rectum  is  in  direct  contact  with  the 
bladder. 

Atresia  affecting  a  segment  of  the  vaginal  lumen, 
usually  the  lower  part,  is  comparatively  common,  and 
may  be  congenital  or  acquired. 

According  to  some  investigators,  notably  Nagel, 
most  cases  of  atresia,  even  in  the  new-born,  are  not 
strictly   developmental   anomalies,   but   the   effect   of 


314 


GYXECOPLASTIC    TECHNOLOGY. 


prenatal  adhesions.  In  other  cases  the  atresia  results 
from  infantile  vulvitis  due  to  gonorrhea  or  any  of 
the  exanthemata.  There  may  be  only  a  superficial 
epithelial  agglutination  of  the  apposed  surfaces,  or 

the  occlusion  may  present  a  membrane  of  varying 
thickness  and  resistance. 

It  is  onlv  Avithin  recent  years  that  successful 
methods  for  the  construction  of  a  permanent  artifi- 
cial vagina  have  been  evolved.     All  former  attempts, 


Fig.  147. — Formation  of  an  artificial  vagina  from  an  intestinal 
loop.  I,  Deformity  (absence  of  vagina)  here  shown.  The  tissues 
are  to  be  separated  along  line  indicated  by  arrow,  up  to,  but  not 
through,  the  peritoneum.  II,  The  canal  for  the  vagina  has  been 
completed,  and  packed  with  gauze.  The  forceps  pushing  against 
the  peritoneum  is  to  be  used  in  a  subsequent  step  of  the  operation. 


which  consisted  mainly  of  skin  transplantations  into 
the  tunneled  rectOA^esical  septum,  were  futile. 

In  1907  Baldwin  devised  and  practised  the  inter- 
position of  an  intestinal  loop  as  a  permanent  substi- 
tute for  the  vaginal  canal,  in  the  following  manner : — 


OPERATIONS  FOR  MALFOi^JMATlONS.  315 

1.  The  patient,  prepared  for  both  perineal  and 
abdominal  operation  (intestinal  resection),  is  placed 
in  the  lithotomy  position.  A  transverse  incision  is 
made  in  the  vulvar  area  between  the  meatus  urina- 
rius  and  anus,  through  the  integument  and  fascia  to 
the  areolar  tissue,  in  which  discreet  blunt  dissection, 
carried  upward,  separates  the  bladder  and  rectum 
as  far  as  the  peritoneal  reflection. 

When  the  dissection  has  reached  the  peritoneum, 
the  cavity  is  widened  in  all  directions  to  an  ample 
degree,  without  penetrating  the  abdominal  cavity, 
and  is  packed  with  sterile  gauze. 

2.  The  patient  is  now  placed  in  the  horizontal 
position,  and  the  abdomen  opened.  A  loop  of  ileum, 
about  12  inches  long,  is  selected  to  serve  as  a  substi- 
tute for  the  vaginal  canal.  Its  mesentery  must  be 
sufficiently  long  to  permit  of  downward  displacement 
and  implantation  without  tension. 

The  loop  is  emptied  of  its  contents  by  pressure, 
and  severed  at  both  ends,  as  for  intestinal  resection, 
with  preservation  of  its  mesentery. 

The  continuity  of  the  ileum  is  restored  by  a 
Murphy  button  or  suture,  while  the  ends  of  the  iso- 
lated loop  are  securely  inverted  by  the  purse-string 
method. 

The  peritoneal  reflection  between  the  bladder  and 
rectum  is  now  opened,  the  gauze  packing  removed 
from  below,  where  a  sponge-holder  is  introduced, 
passed  upward,  and  made  to  grasp  the  centre  of 
the  resected  intestinal  segment,  which  is  drawn  into 
the  artificial  canal  to  the  vulvar  introitus. 

The  parietal  peritoneal  edges  covering  the  ends 
of  the  loop  are  sutured,  and  the  abdomen  is  closed. 


316 


GYNECOPLASTIC   TECHNOLOGY. 


3.  For  the  next  stage  of  the  operation,  the  pa- 
tient is  returned  to  the  Hthotomy  position,  the  apex 
of  the  bowel  loop  is  opened,  and  its  edges  are  sutured 
to  the  surrounding  cutaneous  margin. 

Each  arm  of  the  loop  is  then  cleansed  of  all 
mucus,  and  lightly  packed  with  gauze  to  secure  union 
of  the  loop  surfaces  to  the  walls  of  the  vaginal  cavity. 

4.  After  three  weeks,  or  when  the  patient  has 
fully  recovered  from  the  operation,   the   septum   or 


Fig.  148. — I,  The  intestinal  resection  has  been  completed,  and 
the  intestinal  loop  has  been  grasped  with  the  forceps  preparatory  to 
drawing  it  into  the  prepared  canal.  II,  The  intestinal  loop  drawn 
into  place.  The  cul-de-sac  peritoneum  should  be  closed  over  the 
ends  of  the  loop,  but  not  in  a  way  to  interfere  with  the  circulation 
in  the  mesentery. 


Spur  between  the  two  arms  of  the  loop  is  divided, 
converting  their  lumina  into  a  single  wide  channel. 
This  may  be  accomplished  by  inducing  pressure 
necrosis.  A  long  clamp  is  introduced,  one  blade  into 
the  upper  and  one  into  the  lower  arm  of  the  loop. 
The  clamp  is  firmly  locked,  and  left  in  situ  until  its 


OPERATIONS  FOR  MALFORMATIONS.  317 

bite  sloughs  through,  which  usuahy  occurs  in  about 
five  days. 

Another  method  consists  in  the  appHcation  of 
two  clamps,  a  short  distance  apart,  between  which 
the  septum  is  incised,  the  clamps  remaining  on  the 
tissues  just  long  enough  to  insure  against  hemor- 
rhage, i.e.,  about  twenty-four  hours. 

Baldwin,  in  reporting  his  fourth  case  (Journ.  A. 
M.  A.,  vol.  54,  1910),  states: — 

''While  studying  the  technique  of  this  operation 
from  a  theoretical  point  of  view,  I  took  pains  to  ex- 
amine the  ileum  and  sigmoid  in  a  large  number  of 
patients  on  whom  I  was  doing  ordinary  abdominal 
operations.  Several  hundred  patients  were  thus  ex- 
amined, and  in  all  I  found  that  there  would  be  no 
difficulty  in  drawing  down  such  a  loop  of  ileum  into 
the  vagina,  or  a  loop  of  sigmoid,  if  for  any  reason 
the  ileum  should  not  be  found  satisfactory. 

"With  either,  there  would  be  plenty  of  mesentery 
slack,  so  that  the  circulation  would  not  be  interfered 
with.  I  have  always  used,  however,  a  loop  of  ileum, 
because  resection  of  the  ileum  is  safer  than  resection 
of  the  sigmoid.  In  all  of  my  cases  operative  recov- 
ery was  absolutely  smooth,  and  the  new  vagina  seems 
to  take  the  place  very  satisfactorily  of  the  natural 
organ.  I  was  induced  to  use  the  bowel  for  this  pur- 
pose, because  a  very  extensive  study  of  the  literature 
had  shown  that  all  other  methods  resulted  in  almost 
complete  failure,  although  full  of  promise  in  many 
cases  when  the  patient  left  the  operating  table.  By 
the  use  of  the  bowel  a  normal  mucous  membrane  is 
provided,  surrounded  by  normal  connective  and  mus- 
cular tissue,  and  with  an  ample  blood  supply. 


318 


GYNECOPLx\STIC   TECHNOLOGY. 


''The  dangers  of  operation  are  simply  those  in- 
herent in  any  other  dehberate  resection  and  anasto- 
mosis of  intestine,  but  the  operation  is  one  which 
should  certainly  not  be  undertaken  by  a  tyro  in  surg- 
er3A.  .  .  .  Nevertheless,  the  danger  should  be  fully 
explained  to  the  patient,  who  would  then  decide 
whether  the  risk  is  worth  the  while." 

Wallace  (Buffalo  Med.  Journ.,  Feb.,  191 1)  re- 
ports a  case  in  which  he  opened  the  abdomen,  in- 


Fig.  149. — I,  The  intestinal  loop  in  place  and  opened;  the  mar- 
gins of  the  opening  sutured  to  the  surrounding  surface.  II,  Divid- 
ing the  septum  between  the  two  portions  of  the  intestinal  loop. 
This  is  carried  out  some  days  after  the  operation. 


tending  to  do  the  Baldwin  operation.  Finding,  how- 
ever, that  the  mesentery  of  the  ileum  was  too  short, 
he  utilized  a  loop  of  the  sigmoid,  resecting  5  inches. 
One  end  was  turned  in  and  closed,  the  other  was 
drawn  down  and  stitched  to  the  vulva. 

The  ultimate  result  was  excellent. 

G.    Schubert    (Surg.    Gynec.    and    Obst.,    19 14) 


OPERATIONS  FOR  MALFORMATIOxXS.  319 

devised  a  method  which  utiHzes  a  segment  of  the 
rectum  in  the  formation  of  an  artificial  vagina.  It 
has  given  excellent  results,  and  there  is  no  invasion 
of  the  peritoneal  cavity,  with  its  attendant  dangers. 
The  steps  of  this  procedure  are  as  follows : — 

I.  With  the  patient  lying  on  the  left  side,  the 
hymen  is  completely  excised,  but  no  deeper  dissec- 
tion is  made.  The'sphinctre  ani  is  then  moderately 
dilated,  and  a  circular  incision  is  carried  around  the 
anus  at  the  mucocutaneous  junction. 


Fig.  150. — Artificial  vagina  from  a  section  of  the  rectum.  I, 
The  hymenal  area  has  been  excised,  and  the  end  of  the  rectum 
mobilized  by  dissection  around  the  anus.  II,  An  incision  has  been 
made  over  the  coccyx,  the  bone  removed,  and  a  loop  of  the  rectum 
brought  out.  A  double  ligature  has  been  introduced  and  divided, 
making  two  ligatures.  By  pulling  these  in  opposite  directions,  an 
opening  is  made  in  the  vascular  tissue,  beneath  the  rectum. 
Through  the  opening  a  strip  of  gauze  is  to  be  passed  for  traction 
on  the  rectal  loop. 

The  rectal  mucosa  is  then  carefully  dissected  all 
around  from  the  sphinctre  and  upward  for  about  an 
inch.  The  bleeding  is  checked,  and  the  rectum  closed 
by  a  temporary  suture.  It  is  well  to  have  this  suture 
long  for  traction  purposes  in  the  subsequent  steps. 


320 


GYNECOPLASTIC   TECHNOLOGY. 


2.  The  coccyx  is  excised  through  a  longitudinal 
incision,  4  inches  long,  extending  to  within  2  inches 
of  the  anus.  The  cut  is  carried  down  to  the  bone,  the 
fascia  pushed  aside,  and  the  coccyx  seized  with  a 
bone  forceps  and  disarticulated.  The  underlying 
pelvic  fascia  is  divided  longitudinally,  exposing  the 
rectal  wall. 

3.  The  rectum  is  drawn  into  the  wound,  and  a 
long  double  ligature  is  passed  around  it  4  inches 
above  the  anus.     The  ligature  is  divided,  giving  two 


Fig.  151. — I,  The  gauze  strip  has  been  placed,  and  traction  is 
being  made.  As  the  loop  of  rectum  is  drawn  down,  all  resisting 
bands  of  tissue  are  ligated  and  divided,  as  here  indicated.  II,  The 
loop  of  rectum  has  been  divided  at  the  point  where  the  double 
ligature  was  first  passed,  4  inches  (12  cm.)  above  the  anus.  At  the 
point  of  division  of  the  rectum  the  proximal  end  is  closed  tempor- 
arily, and  covered  with  gauze,  while  the  distal  end  is  closed  per- 
manently with  sutures,  as  here  shown. 


ligatures.  By  separating  and  manipulating  the  liga- 
tures, the  rectum  is  isolated  and  space  obtained  for 
the  introduction  of  a  gauze  loop,  by  means  of  which 
the  rectum  may  be  pulled  upon  without  injury  to  its 
walls. 


OPERATIONS  FOR  MALFORMATIONS.  321 

Traction  upon  the  exposed  rectum  brings  its  up- 
per part  within  reach,  which  is  mobilized  by  sever- 
ing blood-vessels  and  any  restraining  bands  after 
double  ligation.  This  upward  liberation  is  continued 
until  the  rectal  tube  is  sufficiently  freed  to  permit  the 
level  of  its  proposed  division  to  reach  the  anus.  The 
peritoneum  should  not  be  opened,  but  pushed  up  in 
advance  of  the  blunt  dissection. 

The  rectum  is  cut  across  between  two  clamps,  the 


Fig.  152. — Sectional  view,  depicting  the  later  steps  in  the  opera- 
tion. 1,  The  forceps  drawing  forward  the  anal  end  of  the  rectum 
has  been  introduced  from  the  hymenal  area  along  the  canal,  and  is 
grasping  the  temporary  suture  closing  the  anal  end  of  the  rectum. 
II,  Operation  completed. 

Upper  cut-end  is  temporarily  closed  by  suture,  and 
enveloped  in  sterile  gauze;  the  lower  end  is  perman- 
ently sealed  by  inversion. 

4.  Blunt  dissection  tunnels  a  channel  from  the 
hymen  upward  and  backward  until  it  encounters  the 
rectal  wall  at  the  upper  limit  of  the  dissected  area. 

This  artificial  canal  is  widened  to  the  capacity  of  two 

21 


322  GYNECO PLASTIC    TECHNOLOGY. 

fingers,  a  forceps  is  introduced,  and  the  ends  of  the 
lowest  temporary  suture  (first  introduced  and  left 
long  for  traction)  are  seized  and  drawn  to  the  de- 
nuded hymenal  border,  to  the  circumference  of  which 
the  rectal  stump  is  sutured  after  removal  of  the 
temporary  suture. 

The  upper  cut-end  of  the  rectum  is  now  brought 
down  and  united  to  the  anal  rim.  The  first  sutures 
are  buried  and  deeply  placed,  uniting  the  sides  of  the 
rectal  tube  to  the  adjacent  sphinctre,  the  end  of  the 
rectum  is  then  secured  to  the  cutaneous  margin. 

5.  Inclosing  the  coccygeal  wound,  a  drain  should 
be  inserted.  The  new  vagina  is  divulsed  by  a  specu- 
lum, cleansed  and  packed. 

G.  Schubert,  at  the  time  of  his  report  (Surg. 
Gynec.  and  Obst.,  vol.  19,  1914),  had  operated  on 
four  patients.  The  method  was  also  emplo3"ed  by 
Floel,  Franque,  Kromer,  Strassman,  and  Engelman. 
Nine  cases  have  been  under  observation  to  the  pres- 
ent time,  with  extremelv  favorable  results. 


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326  LITERATURE   QUOTED. 

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Am.  Med.  Assoc,  Sept.  10,  1910. 

Martin,  A. :    Frauenkrankheiten,  Vienna,  1885. 

Martin,  Ed. :  Zur  Anatomie  und  Technik  der  Levator,  Fasciennaht, 
1912.    Arch.  f.  Gynaek,  vol.  xcvii,  No.  2. 

Maydl,  K. :  Ueber  die  Radikaltherapie  der  Blasenektopie.  Wiener 
Med.  Wochenschr.,  1894,  25 ;  1896,  28. 

Mayo,  Charles :  Exstrophy  of  the  Bladder.  Jour.  Am.  Med.  Assoc, 
1917,  vol.  Ixix,  No.  25. 

Mange,  K. :    Handbuch  d.  Geschlechtskunde,  Vienna,  1912,  2,  323. 

Milner :     Centralbl.  f .  Chirurg.,  1905,  p.  802. 

Montgomery,  E.  E. :  Vaginouterine  Prolapse  and  Its  Effective 
Treatment.    Jour.  Am.  Med.  Assoc,  1913,  vol.  Ixi,  No.  14. 

Moynihan,  G.  A. :  Extroversion  of  the  Bladder.  Annals  of  Sur- 
gery, February,  1906. 

Mojmihan,  G.  A. :     Lancet,  March  2,  1900. 

Neugebatier :     Deutsch.  Chirurg.,  1905,  46  C. 

Newland :     British  Med.  Journal,  April,  1906. 

Noble,  Kelly,  and  Noble :    Gynec.  and  Abdom.  Surgery.,  Phila.,  1908. 

Noble,  G.  H. :  Intra-abdominal  Dynamics  and  Mechanical  Prin- 
ciples Involved-  in  the  Cause  of  Backward  and  Downward  Displace- 
ments of  the  Uterus.    Surg.,  Gynec,  and  Obstet.,  vol.  xx.  No.  1,  1915. 

Ossing,  J. :    Inaug.  Thesis,  Kiel,  1913. 

Pare,  Ambroise :  Opera  Ambrosii  Pare  regis  primarii  et  Paris- 
iensis  Chirvtrgi,  etc.,  Parisiis,  J.  Dupays,  1582,  Liber,  xviii,  chap,  xxvii, 
p.  698. 

Ibid:  The  works  of  that  famous  chirurgeon,  Ambrose  Parey, 
translated  out  of  the  Latin  and  compared  with  the  French  by  Th. 
Johnson,  etc.,  London,  R.  Cotes,  1649,  Lib.  xxiv,  chap,  xxvii,  p.  615. 

Pare,  Ambroise :     Oeuvres  d' Ambroise  Pare,  Lib.  xxiv,  1012. 

Pasteau :    Ann.  d.  Mai,  1908,  xxvi,  836. 

Peters,  G.  A. :     British  Med.  Jour.,  June  22,  1901. 

Peterson,  Reuben :  Substitution  of  the  Anal  for  the  Vesical 
Sphinctre  in  Certain  Cases  of  Inoperable  Vesicovaginal  Fistute.  Surg., 
Gynec,  and  Obstet.,  1917,  vol.  xxv,  No.  4. 

Piquand  and  Renaud :  The  Levator  Pubovaginalis  and  Genital  Pro- 
lapse, Revue  d.  Gynec.  et  de  Chirurg.  Abd.,  1908,  No.  1. 

Pique:  Discussion  of  Chaput's  paper,  Cong.  Franc  de  Chirurg, 
1892,  6th  session,  p.  618. 

Poirier,  P. :  Lymphatiques  des  Organes  Genitaux  de  la  Femme, 
Paris,  Loerosinier,  1890. 

Polese :     Zentralbl.  f .  Gynaek,  1916,  p.  284. 

Reynolds,  Edward,  and  Lovett,  R.  W. :  An  Experimental  Study  of 
Certain  Phases  of  Chronic  Backache.  Jour.  Am.  Med.  Assoc,  March 
26,  1910. 


LITERATURE   QUOTED.  327 

Reynolds,  Edward :  The  Etiology  of  the  Ptoses,  and  their  Rela- 
tion to  Neurasthenia.    Jour.  Am.  Med.  Assoc,  Dec.  3,  1910. 

Reynolds,  Edward :  Prognosis  of  Sterility.  Jour.  Am.  Med. 
Assoc!,  Oct.  2,  1915. 

Reynolds,  Edward:  Forward  P'ixation  of  the  Cervix  as  a  Pre- 
disposing Cause  of  Some  Retrodeviations  of  the  Uterus,  and  an 
Operation  for  Its  Release.  Surg.,  Gynec,  and  Obstet.,  1914,  vol. 
xix,  p.  588. 

Ristine,  C.  E. :    Am.  Jour.  Obstet.,  vol.  xli,  p.  365. 

Rosenow,  E.  C,  and  Davis,  C.  H. :  The  Bacteriology  and  Experi- 
mental Production  of  Ovaritis.  Jour.  Am.  Med.  Assoc,  1916,  vol. 
Ixvi,  No.  16. 

Ruge  and  Veit :    Zeitschr.  f.  Geburtshilfe  und  Gynaek,  1881,  p.  261. 

Rydygier:     Berl.  Klin.  Woch.,  1887,  No.  31. 

Sampson :     Johns  Plopkins  Bulletin,  1904,  xv,  285. 

Sappey,  M.  P.  C. :  Anatomie-Physiologie-Pathologie  des  Vaisseaux 
lymphatiques  consideres    chez    I'homme    et   les   vertebres,    Paris,    1874. 

Schaefer:     Physiology,  London,  1900,  ii,  44,  162. 

Schaeffer,  Oskar:  Atlas  and  Epitome  of  Gynecolog}^  Philadelphia, 
Saunders,  1900. 

Schauenstein :    Arch.  f.  Geburtsh.  u.  Gynaek,  lix. 

Schauta :    Monatschr.  f .  Geburtsh.  u.  Gynaek,  1902,  xv,  133. 

Schwarz,  G. :     Inaug.  Dissert,  Berlin,  1893. 

Schuchardt:  Arch.  f.  Klin.  Chirurg,  1896,  liii,  474.  Zentralbl.  f. 
Chir.,  1893,  xx,  1121.  Monatschr.  f.  Geburtshilfe  und  Gynaek.,  1901, 
xiii,  744. 

Schlimpert :     Zentralbl.  f.  Gynaek.,  1911,  xxxv,  477. 

Sherman,  H.  M. :  Exstrophy  of  the  Bladder — Successfully  Treated 
by  Peters  Method,  Journ.  Am.  Med.  Assoc,  Sept.  23,  1905. 

Simon,  G. :     Wien.  Med.  Woch.,  1876,  xxvii. 

Simon,  G. :  Ueber  die  Behandlung  der  Blasenscheidenfisteln, 
Giesen,  1854. 

Sims,  J.  Marion :  On  the  Treatment  of  Vesicovaginal  Fistula.  Am. 
Jour.,  Med.  Scien.,  1852,  vol.  xxiii,  p.  59. 

Sims,  J.  Marion:  Amputation  of  the  Cervix.  Trans.  Med.  Soc, 
N.  Y.,  1861. 

Sinclair:    Jour.  Obstet.  and  Gynec,  Brit.  Emp.,  1906,  ix,  241. 

Sitzenfrey :    Zeitschr.  f.  Geburtsh.  u.  Gynaek,  lix. 

Stein,  Arthur :  Esthiomene  and  Secondary  Elephantiasis  Vulvae. 
Surg.,  Gynec,  and  Obstet.,  1912,  vol.  xiv,  345. 

Stein,  Arthur :  Primary  Carcinoma  of  the  Vulva.  Am.  Jour,  of 
Obstet.  and  Dis.  of  Women,  1916,  vol.  Ixxiv,  p.  577. 

Stoeckel,  W. :     Zentralbl.  f.  Gynaek.,   1909,  xxxi,   1. 

Stoeckle,  W. :  Ueber  Radikalheilung  des  Vulvacarcinom.  Muench 
Med.  Wochenschr.,  1910,  No.  9. 

Idem  :     Muench  Med.  Wochenschr,  1912,  No.  8. 


328  LITERATURE    QUOTED. 

Idem  :    Zentralbl.  f.  Gynaek,  1912,  Xo.  34. 

Idem  :     Zentralbl.  f .  Gynaek,  1909,  xxi.  No.  1. 

Sturmdorf,  Arnold  :  Studies  on  a  Local  Hjematologic  Factor  in  the  Cau- 
sation of  Uterine  Hemorrhage.     N.  Y.  State  Jour,  of  Med.,  Oct.,  1911. 

Sturmdorf,  Arnold :  Perineorrhaph}-  in  Principle  and  Practice.  Am. 
Jour,  of  Obstet.  and  Dis.  of  Women,  1912,  vol.  Ixvi,  No.  3. 

Sturmdorf,    Arnold :      Perineum-,    Perineorrhaphy    and    Prolapse. 
N.  Y.  Medical  Record,  April  1,  1905. 

Sturmdorf,  Arnold :  The  Functional  Metrorrhagias.  Jour.  Am. 
Med.  Assoc,  1914,  vol.  Ixii,  507. 

Sturmdorf,  Arnold :  Tracheloplastic  ^Methods  and  Results.  Surg., 
Gynec,  and  Obstet.,  1916,  pp.  93-104. 

Sturmdorf,  Arnold :  Cong-enital  and  Acquired  Retropositions  of 
the  Uterus.  Am.  Jour,  of  Obstet.  and  Dis.  of  Women  and  Child.,  1916, 
vol.  Ixxiv,  No.  3. 

Sturmdorf,  Arnold :  The  Cervicoplastic  Treatment  of  Sterility. 
Am.  Jour.  Obstet.  and  Dis.  of  Women,  1917,  vol.  Ixxvi,  No.  3. 

Sturmdorf,  Arnold :  Chronic  Endocervicitis.  Trans.  Amer.  Med. 
Assoc,  1917,  Section  Obstet.  and  Gimec. 

Tait,  Lawson :  Diseases  of  Women  and  Abdominal  Surgerv,  Phila., 
1889,  vol.  i,  p.  68. 

Taussig,  F.  J. :  Etiologic  Study  of  Vulvar  Carcinoma.  Am.  Jour. 
Obstet.  and  Dis.  of  Women,  1917,  vol.  Ixxvi,  No.  479. 

Thomas,  T.  G. :  A  Practical  Treatise  on  the  Diseases  of  Women, 
N.  Y.,  1880. 

Thompson,  J.  E. :  An  Anatomical  and  Experimental  Study  of 
Sacral  Anjesthesia.    Ann.  of  Surgery,  1917,  vol.  lx\-i.  No.  6. 

Tiegerstedt :     Textbook  of  Physiology-,  1906. 

Trendelenburg,  F. :  Zur  Operation  der  Ectopia  Vesicae-Zentralbl. 
f.  Chirurg,  1885,  p.  857. 

Trendelenburg,  F. :     Saninil.  Klin.  Vortr,  1890,  No.  355. 

Veit :    Handb.  d.  Gynaek,  1907,  vol.  ii. 

Vineberg,  Hiram :  Complete  Procidentia  in  a  Nullipara.  Am.  Jour. 
Obstet.  and  Dis.  of  Women,  1917,  vol.  Ixxv,  1060. 

Waldeyer :    Arch,  f .  Path.  Anat.,  etc.,  Iv, 

Ward,  George  Graj-,  Jr. :  The  Operative  Treatment  of  Inaccessible 
Vesicovaginal  Fistulse.    Surg.,  Gynec,  and  Obstet.,  1910,  xi,  22. 

Ibid :  1917,  vol.  xxv.  No.  2,  126. 

Warren,  C. :  Operation  for  Complete  Tear  of  the  Perineum, 
Trans.  Amer.  Gynec.  Soc,  1882. 

Watson,  C.  M. :  The  Anatomic  Repair  of  the  Female  Pelvic  Floor. 
Surg.,  Gynec,  and  Obstet.,  1911,  vol.  xii,  No.  6. 

Wertheim,  E. :    Arch.  f.  Gjmaek,  1914,  cii,  201. 

Winiwarter :     Chirurg.  Ivrankheiten  d.  Haut. 

Ziegenspeck,  quoted  by  Ed.  Martin :  Arch.  f.  Gynaek,  1912,  vol. 
xcvii,  No.  2. 


INDEX. 


Abdominal  cavity,  axis  of,   155 
Abortion,  habitual,  51 
Abscess,  of  broad  ligament,  46 
Absorption,  drug  from  vagina,  11 
Adnexa,  absence  of,  279 
Adnexitis,  46 
Albumen,  15 
Amenorrhea,   50 
Anemia,  secondary,  6 
Anesthesia,  general,  5 

regional,  17 

sacral,  17 
Anal    sphinctre,    laceration 
through,  198 
repair  of,  198 
suture  of,  201 

plate,  277 
Androgyny,  304 
Anus  primitive,  276 
Apron  flap,  formation  of,  200 

for    complete    lacerations,    200, 
202 
Artery,  internal  pudic,  135 
Atresia  of  cervix,  280 

of  hymen,  299 

of  vagina,  292 

of  vulva,  295 
Atresia  ani  vaginalis,  295 
Axis  of  abdominal  cavity,   155 

of  pelvic  cavity,  155 

B 

Bladder,  cornua,  172 
exstrophy  of,  240 
hernia  of,  97,  164 
ligaments  of,  170 
pillars,  175 
mechanism  of,  172 
prolapse  of,  164 


Bladder,  topography  of,  170 
Blood-pressure,  6 
Broad   ligament,   abscess,   chronic, 
46 

C 
Caffeine,  in  shock,  14 
Camphor,  in  shock,  14 
Cancer,  uterine,  63 

of  vulva,  252 
Cardiac  murmurs,  6 

dilatation,    acute,    postoperative, 
16 

hypertrophy,  6 
Casts,  15 

Catharsis,  preoperative,  8 
Catheterization,  postoperative,    12, 

14 
Cervical  canal,  function  of,  32 

catarrh,  32 

drainage,  43 

erosions,  26,  32 

eversion,  27,  32 

flexion,  51 

lacerations,  direction  of,  66 

laceration,  patholog}'  of,  32 

mucosa,  32 

sphinctre,  43 

ulceration,  26,  32 
Cervix,  amputation  of,  29,  66,  69, 
86, 

atresia  of,  280 

cancer  of,  63 

congenital   deformitj'  of,  79 

conical,  51 

course  of  infection  in,  45 

dilatation  of,  43,  86 

discission  of,  86 

ectropium  of,  32 

flexion  of,  290 

hypertrophy  of,  Z2 

(329) 


330 


INDEX. 


Cervix,  lacerations  of,  26 

lymphatics  of,  44 

musculature  of,  41 

stenosis  of,  86,  280 
Clitoris,  carcinoma  of,  261 

cleft,  240 

hypertrophy  of,  297 

lymphatics  of,  259 
Coagulation,  inhibition  of,  48 
Coccygeal  plexus,  21 
Colon  bacillus  infection,  56 
Colpocele,  91,  164 
Colpocleisis,  230 
Colpoperineotomie  laterale,  220 
Colporrhaphy,  168 
Congenital  fistulse,  280 

malformations,  275 

post-rectal  cysts,  250 

uterine  displacement,  151 
Curettement,  58 
Cystocele,  97,  164 

operations   for,  174 
Cystitis,    10 

D 
Decensus  uteri,  97 
Diet,  preoperative,  8 

postoperative,  8 
Dilatation,  58 
Dysmenorrhea,  50 
Douglas's  pouch,  spiral  suture  of, 

196 
Dressings,  13 
Dyspareunia,  293,  312 
Dj^stocia,  cervical,  7Z 


Elephantiasis  vulvae,  268 
Endocervicitis,  32,  54,  55 

treatment  of,  58 

as  a  cause  of  sterility,  51,  84,  87 

etiology  of,  53 

infantile,  53 

virginal,  53 

as  a  precancerous  stage,  63 

spennatocidal  effect  of,  51 

toxemia  of,  52 


Endometrium  corporeal,  32 
bacteriology  of,  35 
glandular  hyperplasia,  34 
menstrual  cycle  of,  38 

Endometritis,  chronic,  32 
hypertrophic,  34 

Endotrachelitis,  32 

Enemata,  16 

Entero-genital  fistulse,  246 

Entero-vaginal  fistulje,  246 

Epidural  space,  17 

Episiocleisis,  230 

Epispadias,  298 

Erosions  of  cervix,  26 

Erosion,  glandular,  27 

Escharotics,  58 

Esthiomene,  vulvae,  269 

Ether  effects,  5 

Exophthalmic  goiter,  9 

Exstrophy,  of  bladder,  240 


Fascia  pelvic,  function  of,  115 
superficial,  115 
deep,  115 

perineal,  122 

levator,  117 

recto-vesical,  117 
Fascial  overlapping,  147 
Fecal  fistulse,  246 

incontinence,  198 
Feces,  impacted,  8 
Fistula,  congenital,  250 

entero-genital,  246 

entero-uterine,  246 

fecal,  246 

post-rectal,  250 

recto-perineal,  249 

recto-vaginal,  248 

Schuchardt's  incision  for,  216 

uretero-vaginal,  215 

utero-vesico-vaginal,  215 

vagino-perineal      incisions      for, 
218 

vesico-uterine,  213 

vesico-utero-vaginal,  213 


IXDEX. 


331 


Fistula,  vesico-vaginal,  200 

Flap    splitting    for    vesico-vaginal 

fistula,  211 
Flaps,  formation  of,  13 
Flatus,   15 

Flexion  of  cervix,  291 
Fetal  rudiments,  275 


Gastro-intestinal  complications,  8 
Genital  groove,  277 

tubercle,  277 
Glands,  bartholinian,  122 
Glandular  erosion  of  cervix,  27 
Goffe,  J.  Riddle,  185 
Gonorrhea,  10 
Gynecomastia,  306 
Gynandry,  304 

H 
Hematometra,  293,  302,  303 
Hematocolpos,  293,  302,  303 
Hematosalpinx,  302,  303 
Hemorrhage,  3,  10,  13,  48 
Heart,  functional  capacity  of,  7 
Hemorrhoidal,  plexus,  21 
Hiatus,  sacralis,  18 
Hydrosalpinx,  46 
Hymen,  atresia  of,  299 
Hymen,  imperforate,  299,  311 
Hymen,  malformations  of,  298 
Hyperthyroidism,   10 
Hypertension,  4 
Hypnotics,  10 
Hypospadias,  296 
Hysterectomy,    vaginal     for    pro- 
lapse, 179,  187,  188.  190 


Imperforate  hymen,  299,  311 

Incompetence  of  vesical  sphinctre, 
235 

Incontinence,  urinary,  234 

Infection,  3 

Infantilism,  306 

Inhibition  of  coagulability  in  men- 
strual blood,  48 


Intermenstrual  hemorrhage,  47 
Intestinal  stasis,  8 
Intra-abdominal  pressure,  dynam- 
ics of,  97 
deflection  of,  101 
Intrapelvic  support,  93 
Iodine,  tincture  of,  12 
Irrigation,  vaginal,  11,  13 

K 

Kidneys,  functional  test  of,  7 


Laceration  of  cervix,  26 
complications,  45 
pathologj^  Z2 
through  anus,  198 
Laxatives,  15 
Leucorrhea,  46 

Levator    ani,    coccygeal    segment, 
110 
exposure  of,  127 
paralysis  of,  107 
pubic  segment,  110 
cleft,  113 
interposition,  137 
myorrhaphy,   124 
sheaths,  135 
Ligament,  pubo-cervical,  175 
round,  function  of,  162 
vaginal  fixation  of,  184 
vaginal  shortening  of,  184 
uterine,  mechanism  of,  104 
Lumbar  index,  156 

determination  of,  156 
Lpnphangioma  of  vulva,  271 
Lymphatics  of  adnexa,  45 
of  cervix,  -14 
of  clitoris,  259 
in  broad  ligament,  45 
peritubal,  45 
periovarian,  45 
of  urethra,  259 
of  uterus.  44 

^I 
Malformations,     congenital,     275, 
309 


332 


INDEX. 


Menorrhagia,  47,  50 

Menstrual    blood,    incoagulability 

of,  48 
Metrorrhagia,  47 
Morphine,  9,  14 
Miillerian  ducts,  275 
Muscle,  bulbo-cavernosus,  122 

bulbo-vestibuli,  122 

constrictor  cuni,  123 

deep  transversus  perinei,  122 

superficial    transversus    perinei, 
122 

sphinctre  vaginae,  123 
Myodynamics   of   levator  ani,   109 
Myometritis,  49 
Myometrium,  arrangement  of,  40 

contractions  of,  40 

N 
Xabothian  follicles,  27 
Nephritis,  7 
Neurosis,  reflex,  52 
Novocain,  22 

O 

Os,  pin-hole,  51 
Ovarian  sclerosis,  46 


Papillary   erosion   of   cervix,  26 
Pelvic  abscess,  46 

cavity,  axis  of,  155 

floor,  mechanism  of,  93 

fascia,  115 

overlapping  of,  181 

outlet,  122 
Pelvis,  angle  of,  101 

planes  of,  101 

rotation  of,  101 

vertical,  156 
Peridural  space,  22 
Perineal  fascia,  122 

lacerations,  124 

laceration,  complete,  198 

plexus,  21 
Perineoplast}^,  88 
Periadnexitis,  46 


Perioophoritis,  50 
Perisalpingitis,  51 
Perineorrhaphy,  88 
Perineum,  rudimentary,  277 
Plexus,  recto-vaginal,  131 
Poisoning  from  vaginal  irrigation, 

11 
Post-rectal  cysts,  250 
Precancerous  conditions,  63 
Prolapsus  uteri,  97,  193 

vaginae,  97 
Prolapse,  virginal,  107,  193 
Pseudohermaphroditism,  279,  300 
Pudendal  plexus,  21 
Pubo-coccygeus,  110 
Pubo-rectalis,   110 
Pubo-vaginalis,  110 
Pulse,  7 

Purging,  preoperative,  8 
Pyosalpinx,  46 

R 
Rectal    wall,    anterior,    laceration 

of,  199 
Rectocele,  97,  114 
Recto-perineal  fistula,  249 
Recto-vaginal  fistula,  248 
Retroposed  uterus,  150 
Retroverted  uterus,  151 
Retroversion  operations,  161 
Round    ligaments,    shortening    of, 
184 

S 
Sacral  anesthesia,  17 

blocking,  17 

canal,  17,  18 

cornua,  18 

hiatus,  18 
Sacro-coccygeal  ligament,  19 
Sacro-lumbar  angle,  159 
Sacro-uterine   ligaments,   mechan- 
ism of,  160 
Sacro-vertebral  angle,  155 
Sactosalpinx.  46 
Shock,  treatment  of,  3,  13,  14 
Septa,  vaginal,  299 
Septum,  recto-vaginal,  198 


INDEX. 


333 


Sexual  characters,  secondary,  307 
Spcrmatocidal,  effect  of,  endoccr- 

vicitis,  51 
Sphinctre,  anal,  repair  of,  203 

laceration,  subcutaneous,  207 

vesical,  incompetent,  234 
repair  of,  227 
relaxed,  234 
Spina-bifida,    uterine    prolapse    in, 

107,  193 
Spinal  anesthesia,  17 
Splanchnoptosis,  97 
Staphylococcus  infection,  56 
Stenosis  of  cervix,  86,  289 
Stimulants,  cardiac,  9 
Stomach,  dilatation  of,  8 
Streptococcus  infection,  56 
Strychnine,   14 
Sterility,  51,  84,  87 
Sutures,  13 

T 
Thyrotoxicosis,  9 
Toxic  symptoms  of  endocervicitis, 

52 
Trachelorrhaphy,  61,  63 
Tracheloplasty,  26 
Transversus  perinei  muscles,  122 
Triangle,  anterior,  122 

posterior,  122 
Tuberculosis  of  vulva,  270 
Tubal  ostia,  occlusion  of,  51 
Tubo-ovarian  abscess,  46 

cyst,  46 

U 
Ulceration  of  cervix,  32 
Urine,  7,   14,  15 
Urinary     incontinence,     234,     237, 

298 
Ureter,  para-urethral,  237 

supernumerary,  external,  230 

transplantation,  242 
Uretero-vesico-vaginal  fistula,  215 
Uretero-rectal  anastomosis,  241 
Urethra,  absence  of,  297 
Urethral  lymphatics,  259 
Urethro-plasty,  227 


Urogenital  sinus,  278 

Urotropin,  14 

Uterine  atresia  and  stenosis,  289 

circulation,  40 

contractions,  40 

displacement,  congenital,  156 

fibrosis,  46 

lymphangitis,  44 

poise,  normal,  162 

poise,  abnormal,  162 

musculature,  structure  of,  41 

myodyn amies,  69 

tetany,  41 

ventro-suspension,  196 
Utero-vesical  fold,  184 
Uterus,  absence  of,  279 

bicollis,  280 

bicornis,  280,  283 

contractions  of,  40 

course  of  infection  in,  44 

decensus  of,  97 

didelphys,  280,  282 

dilatation  of,  41 

duplex,  280,  285 

fcetalis,  280,  287 

function  in  menstruation,  40 

infantilis,  280,  289 

lymphatics  of,  44 

pessary  support  of,  196 

prolapse  of,  97,  193 

retroposed,  151 

retroverted,  154 

septus,  280,  285 

structure  of,  41 

unicornis,  279,  281 

V 

Vagina,  absence  of,  313 

abnormal     communications     of, 
293 

artificial,  314 

atresia  of,  292,  313 

duplex,  291 

malformations  of,  291 
Vaginal  contours,  normal,   141 

hysterectomy  for  prolapse,  188 


334 


INDEX. 


Vaginal  outlet,  relaxed,  97 

septa,  291 

wall,  ectopia  of,  164 
foreshortened,  83 
Vaginismus,  312 
Vaginitis,  53 
Varix,  traumatic,  135 
Vesical     sphinctre,     incompetence 
of,  234 

laceration  of,  227 

relaxed,  234 

repair  of,  235 
Vesico-vaginal  fistulse,  212 

fistula,    Schuchardt's    incision 
for,  216 
Vesico-uterine  fistula,  213 
Vesico-uterovaginal  fistula,  213 
Visceral  support,  intrapelvic,  93 
Vomiting,  postoperative,  15 


Vulva,    abnormal   communications 
of,  295 

atresia  ani  vaginalis,  295 

atresia  of,  295 

cancer  of,  252 

lymphatics  of,  256 

malformations  of,  291 
Vulvse,  elephantiasis,  268 
Vulvar  dermatitis,  10 

esthiomene,  269 

excoriations,  10 

eczema,   10 

furunculosis,  10 

lymphangioma,  271 

tuberculosis,  269 
Vulvitis,  infantile,  53 

W 

Wolffian  body,  275 


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